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5!K* 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


ESSENTIALS    OF    TROPICAL    MEDICINE. 


BALE'S    MiiDlCAL    BOOKS    AND    JOURNALS. 


ESSENTIALS    OF 

TROPICAL  MEDICINE 


BY 

WALTER   E.    MASTERS,  M.D.Brux..  m.r.c.s.,  L.R.c.p.Lond. 

Graduale  of  the  Loiidoi  School  of  Tiopical  Medicine, 

Felloiv  of  the  Society  of  Tropical  Medicine  and  Hygiene, 

Fellow  of  the  Koyal  Geographical  Society, 

Graduate  and  Felloiv  of  the  Royal  Institute  of  Public  Health, 

Graduate  and  Member  of  the  Royal  Sanitary  Institute, 

Late  Medical  Officer,   Colombia,  South  America, 

Late  Medical  Officer,  Belgian  Congo, 

Late  Surgeon,    Whifps  Cross    War  Hosfital, 

Present  Rledical  Officer,    Gold  Coast,    Il'est  Africa 


Xon^ou 

JOHN     BALE,    SONS    &    DANIELSSON,    Ltd. 

OXFORD    HOUSE 

83-91,  GREAT     TITCHFIELD  STREET,  OXFORD  STREET,  W.  i 

1920 


% 


vl(Ai 


LONDON  : 

JOHN    BALE,    SONS,    AND    DANIELSSON,    LTD. 

83-gi,    GREAT   TJTCMFIEI  D    STREET,    W.I. 


PREFACE. 

The  subject  of  Tropical  Medicine,  considered  in  its  broadest 
sense,  has  become  vaster  tlian  any  other  specialized  branch  of  the 
Medical  Sciences.  The  comprehensiveness  of  the  subject  is  only 
irealized  when  one  undertakes  a  course  of  study  at  one  of  the  Tropical 
Schools,  a  course  particularly  essential,  but  all  too  short  in  order  to 
become  acquainted  with  the  various  branches  of  the  subject.  The 
student  finds  that  he  must  gather  together  his  knowledge  from  as 
many  imposing  text-books  in  the  three  or  six  months  of  his  study  as 
he  required  for  the  whole  of  his  cjualifying  examinations,  a  task  almost 
impossible  in  the  lime.  Also  the  busy  tropical  practitioner,  who 
requires  adequate  essential  information,  cannot  consult  libraries  or 
include  large  volumes  in  his  limited  equipment,  and  if  he  had  them 
he  would  find  it  a  somewhat  laborious  task  to  peruse  them  for  the  few 
essential  facts  he  needed  to  know. 

This  work  contains  nothing  new.  It  is  not  intended  to  sub- 
stitute any  other  work.  It  is  a  digest  of  our  knowledge  of  Tropical 
Medicine,  including  Skin  Diseases,  Eye  Diseases,  Venoms,  Hygiene 
and  Laboratory  Hints  in  a  form  handy  for  ready  reference  :  the 
vade-mecum  of  the  student  and  busy  tropical  practitioner. 

It  was  commenced  for  the  sole  use  of  the  writer,  but  it  has  been 
suggested  that  its  utility  would  be  appreciated  in  a  wider  field.  In 
tlie  event  of  another  edition  being-  required  the  writer  would  welcome 
any  suggestions  for  its  improvement  from  medical  men. 

For  the  illustrations  the  writer  is  much  indebted  to  the  authors  of 
the  following  works  and  to  the  publishers  through  whose  courtesy  their 
loan  was  made  possible  :  — 

"  A  Handbook  of  the  Gnats  or  Mosquitoes,  including  a  Revision 
of  the  Anophelin^e."  By  Lieut. -Col.  George  M.  Giles,  M.B.Lond., 
F.R.C.S.* 

Album  of  Photographs  issued  by  the  South  Indian  Branch  of  the 
B.M.A.     Compiled  by  Major  P.  C.  Gabbett,  I. M.S.* 

"  Amoebic  or  Tropical  Dysentery  :  its  Complications  and  Treat- 
ment."    By  W.  Carnegie  Brown,  M.D.,   M.R.C.P.* 

"Beriberi."  By  Edward  B.  X'edder,  A.M.,  M.D.  New  York: 
William  Wood  and  Co. 

"  Laboratory  Studies  in  Tropical  Medicine."  By  C.  W.  Daniels 
and  H.  B.  Newham.* 


VI  PREFACE 

"  Reports  of  the  Sleeping  vSickness  Commission  of  the  Royal 
Society."     By  F.  W.  Mott,  M.D.,  F.R.S.* 

"  Researches  on  Egyptian  Bilharziosis."  Bv  R.  T.  Leiper,  M.D., 
D.Sc* 

"  Sprue  and  its  Treatment."     By  W.  Carnegie  Brown,   M.D.* 

"The  Animal  Parasites  of  Man."  By  H.  B.  Fantham,  M.A. 
Cantab.;  J.  W.  W.  Stephens,  M.D.Cantab.;  and  F.  V.  Theobald, 
iAL  A. Cantab.* 

"  The  Diseases  of  Warm  Countries."      \\\  Dr.  B.  Scheube.* 

"Webster's  Diagnostic  Methods."  Philadelphia:  P.  Blakiston's 
Son  and  Co. 

"Tropical  Medicine  and  Hygiene."  Bv  C.  W.  Daniels,  ALB., 
F.R.C.P.Lond.* 

"  Venoms  :  \^enomous  Animals  and  Antivenomous  Serum- 
Therapeutics."     By  A.  Calmette,   M.D.* 

W.  F.  M. 

London,   1920. 


*  London  :   Bale,  bons  and  Danielsson,  Ltd. 


CONTENTS. 


SECTION  I. 
Diseases  Dle  to  Protozoa       ...         ...         ...         ...         ...         ...  1 


SECTION    II. 
Diseases  Due  to  Bacteria       ...         ...         ...         ...         ...         ...         161 

SECTION  III. 
Diseases  Due  to  Helminths 226 

SECTION  IV. 
Diseases  of  Uncertain  Etiology      ...         ...         ...         327 

SECTION   V. 
Diseases  Due  to  Venoms  and  Poisons         ...         .  .         419 

SECTION  VI. 
Diseases  of  the  Skin      ...  ...  ...         ...         ...         ...         ...         458 

SECTION  VII. 
Diseases  of  the  Eyes ...         508 

SECTION  VIII. 
Troimcal  Hygiene,  Sanitation,  &c.   ...         ...         ...         ...         ...         530 

SECTION  IX. 
Laboratory  Hints  ...         ...         ...         ...         603 

APPENDIX  667 


ESSENTIALS    OF    TROPICAL    MEDICINE. 


SECTION    I. 
DISEASES    DUE    TO    PROTOZOA. 

INTRODUCTION    TO    PROTOZOOLOGY. 

MODES     OF     TRANSMISSION     OF     PROTOZOAL     DISEASES. 

RELAPSING    FEVER. 

SPIROCH.ETOSIS    ICTEROH/EMORRHAGICA    (WEILS    DISEASE). 

NOTES    ON    TICKS. 

FRAMBCESIA    TROPICA. 

THE    DYSENTERIES. 
Amcebic. 

CiLIAR, 

Leishmanic.     (See  Kala-azar.) 
Laveranic.     (See  Subtertian  Malaria.) 

PSEUDO-DYSKXTERIES.      (See    PSEUDO-DYSENTERIES. ) 

LIVER   ABSCESS. 

AMCEBIC     ABSCESS. 

TROPICAL    LIVER. 

THE     LEISHMANIASES. 
Kala-azar. 

Infantile  Kala-azar. 
Dermal  Leishmaniasis. 

Differentiation  between  Kala-azar  and  Oriental  Sore. 
Naso-oral  and  Oro-phalangeal  Leishmaniasis. 
Canine  Leishmaniasis. 
Pseudo  Kala-azar. 

M.ALARIA. 

The  Malarial  Mosquito. 

TRYPANOSOMIASIS. 

African  Trypanosomiasis. 

South  American  Trypanosomiasis. 

The  Tsetse  Fly. 

Notes  on  Mammalian  Trypanosomiasis. 

T 


2  DISEASES  DUE  TO   PROTOZOA 

DISEASES    DUE    TO    PROTOZOA. 

INTRODUCTION  TO  PROTOZOOLOGY. 

The  Protozoa  are  now  definitely  proved  to  be  factors  of  the 
greatest  importance  in  the  causation  of  Tropical  Diseases.  It  is 
essential  that  all  tropical  practitioners  should  be  acquainted  with  the 
outlines  at  least  of  their  life-history  and  comparative  pathology.  One 
only  has  to  mention  such  diseases  as  malaria,  kala-azar,  trypano- 
somiasis, framboesia  tropica,  and  relapsing  fever  to  indicate  the  large 
amount  of  tropical  pathology  coming  under  this  head. 

DEFINITION. 

Protozoa  are  unicellular  organisms,  occurring  singly  or  in  clusters, 
either  non-parasitic,  parasitic  on  the  lower  animals  only,  parasitic  during 
part  of  their  existence,  or  parasitic  in  different  animals  during  different 
stages  of  their  development,  and  reproducing  themselves — 

Asexually  by  binary  fission  (schizogony) ; 

Sexually  by  budding  (sporogony); 

Sexually  by  rejuvenescence  by  conjugation. 

ORIGIN  OF  INFECTION. 

Very  probably  the  primitive  form  of  protozoon  had  some  of  the 
characteristics  of  the  simple  amoeba.  This  could  be  taken  into  the 
alimentary  tract,  from  thence  into  the  blood-stream,  consequently 
facilitating  blood-sucking  insecta  in  carrying  out  their  part  in  the 
transmission  of  the  protozoa  in  question. 

The  blood  of  man  may  have  been  infected  from  human  intestinal 
excreta  or  from  infective  material  coming  from  the  intestinal  tract  of 
some  invertebrate. 

The  first  form  was  undoubtedly  non-pathogenic,  pathogenicity 
probably  beginning  in  bats  and  birds,  followed  some  time  later  by 
pathogenicity  in  man,   the  intermediate  links  being  lost. 

Some  protozoa  cannot  pass  through  the  placenta,  e.g.,  the  malarial 
parasite,  while  others  can  pass  through  and  infect  the  foetus,  e.g.,  the 
spirochcetes  and  treponemata. 

Many  of  the  insect  "carriers"  infect  their  eggs,  and  thus  hand 
down  the  infection  to  a  new  generation  of  blood-suckers. 

The  hasmatozoan  types  may  live — 

In  the  blood-stream  free,  e.g.,  trypanosomes  ; 

In  the  red  blood  cells,  e.g.,  malarial  parasite; 

In  the  white  blood  cells,  e.g.,  Leishman-Donovan  body  ; 

In  the  endothelial  cells,  e.g.,  Leishman-Donovan  body. 


INTRODUCTION   TO   PROTOZOOLOGY  3 

MORPHOLOGY. 

It  may  be  that  all  protozoa  have  not  yet  been  recognized,  but  some 
of  those  known  are  large,  e.g.,  the  Sarcocystid^e  in  muscle;  and  some 
are  small,  e.g.,  the  Ikemoprotozoa. 

The  protoplasm  consists  of — 

A  clear  hyaline  ectoplasm ; 

A  dark  granular  endoplasm. 

The  protoplasm  contains — 

One  or  more  nuclei,  a  complex  body  of  chromatin  and  achromatic 
substance.     It  may  be  single  or  divided  into  two — 

One  controlling  the  function  of  nutrition — trophonucleus ; 

One  controlling  the  function  of  motion — kinetonucleus,   or 

A  macronucleus  which  is  trophic  and  kinetic ;  and 

A  micronucleus  Avhich  is  purely  reproductive. 

Chromidiosomes  are  smaller  particles  of  chromatin  which  give  rise 
to  the  chromidia,  intra-  or  extra-nuclear. 

Metachromniic  granules  consist  of  chromatic  grains  in  process  of 
ana-  or  kata-bolism. 

Volutine  granules  contain  nucleic  acid  and  food  material  for  the 
nucleus. 

Metaplasmic  granules  are  products  of  cytoplastic  ana-  or  kata- 
bolism. 

Centrosomes,  one  or  two  granules  outside  the  nucleus  essentially 
concerned  in  binary  fission. 

Archoplasm,  the  clear  protoplasm  around  the  centrosome. 

Rhizoplast,  that  portion  of  the  flagellum  which  penetrates  into  the 
cytoplasm. 

Vacuoli,  their  function  may  be — 

Respiratory  and  excretory ; 

Digestive  and  excretory. 

Protozoa  move  by  pseudopodia,  cilia,  or  flagella,  or  they  may 
become  quiescent  and  encysted. 

LIFE-HISTORY. 

Under  favourable  conditions  of  food,  moisture,  temperature,  &c., 
reproduction  is  asexual  and  may  follow  the  methods  of — 

(i)  Binary  fission. 

This  is  single  division  of  the  nucleus  into  two  portions,  followed 
by  the  cytoplasm. 

(2)  Gemmation. 

The  nucleus  divides  into  two  or  more  portions,  Avhich  separate  at 
the  periphery,  each  being  surrounded  by  a  differentiated  portion  of 
the  cytoplasm. 


4  DISEASES  DUE  TO   PROTOZOA 

is)  Spore  Formation. 

A  quiescent  body,  the  schizont,  is  formed.  The  nucleus  and 
cytoplasm  divide  into  a  number  of  asexual  spores  known  as  merozoites, 
leaving,  as  a  rule,  a  "  nucleus  de  reliqual,"  or  rest-bodv.  These 
merozoites  enter  new  cells  in  the  host,  where  they  grow  into  tropho- 
zoites, and  complete  ?.n  asexual  life-cycle  or  the  cycle  of  simple 
schizogony. 

Under  adverse  conditions,  such  as  scarcity  of  food  in  the  host,  &c., 
the  merozoites  develop  into  more  resisting  forms  or  gametocytes.  In 
these  latter  female  and  male  elements  are  separated.  Such  elements, 
nuclear,  may  remain  in  the  same  cell  or  separate  cells.  Usuallv  the 
male  element  of  one  fuses — zygosis — with  the  female  element  of 
another  and  forms  a  new  individual,  with  a  single  new  nucleus  known 
as  a  sporont.  This  reproduces  itself  rapidly  by  binary  fission  or  spore 
formation,  the  resulting  spores  being  known  as  sporozoites. 
(4)  Parthenogenesis.. 

This  is  a  form  of  reproduction  from  the  female  type  of  parasite  as 
may  take  place  in  malaria.  The  female  gametocvte  can  resist  drugs 
in  the  body  and  lie  dormant  until  taken  up  by  a  blood-sucking  insect, 
when  the  nucleus  and  protoplasm  will  divide,  one  portion  disappearing, 
while  the  other  forms  merozoites,  and  starts  the  cycle  of  schizogony 


agam. 


PATHOGENICITY. 

The  pathogenicit}^  of  protozoa  is  considered  under  the  diseases 
caused  by  them. 

CLASSIFICATION. 

There  are  live  groups  :  — 
(i)  The  Sarcodina  (Rhisopoda). 

These  move  by  a  protrusion  of  protoplasmic  processes,  broad  and 
blunt  or  thin  and  sharp.  They  may  or  may  not  be  covered  in  part 
with  shells.  They  multiply  by  budding  or  fission.  Occasionally 
spores  are  formed. 

(2)  The  Mastigophora  (FJagellata). 

These  have  specialized  motile  protoplasmic  processes  known  as 
flagellum  or  flagella.  The  shape  of  the  parasite  is  defined  and  covered 
with  a  membrane. 

They  multiply  by  longitudinal  fission. 

(3)  Sporozoa. 

(A)  Telosporidia. 

In  these  the  spore  formation  is  distinct  from  and  later  than  the 
trophic  phase  of  the  life-cycle. 


INTRODUCTION  TO   PROTOZOOLOGY 


(B)  Neosporidia. 

The  spore  formation  and  trophic  growth  proceed  simultaneously. 
(4)  Ciliata  {Infusoria). 

These  possess  cilia  throughout  their  whole  existence  or  only  during 
the  early  stages  of  their  life-cycle.  The  cilia  are  formed  from  the 
ectosarc  only. 

Reproduction  is  by  transverse  fission  and  budding. 

Protozoologists  may  decide  upon  a  rearrangement  of  this  classi- 
fication later. 

Protozoa  of  pathogenic  significance  in  man  may  be  grouped  as 
follows  :  — 

(i)  Sarcodina. 

Pathogenic  amoeb^u  are  dealt  with  under  Amoebic  Dysentery. 

The  Chlamvdophrys  stercorea,  a  rhizopod,  is  believed  to  be  an 
ama:ba  parasitic  in  man  during  one  stage  of  its  existence.  It  has  been 
found  in  cows,  rabbits,  mice  and  lizards, 

(2)  Mastigophora. 

The  Cercomonas  hominis  is  a  rounded  or  pear- 
shaped  single  flagellated  parasite  found  in  normal 
faeces,  also  in  the  excretions  of  diarrhoea  and  cholera 
patients. 

The  Cercomonas  vaginalis  is  a  similar  parasite  not 
uncommonly  found  in  the  vagina  of  Cingalese  native 
women . 

The  Tetramitus  mesnili  has  a  pear-shaped  body 
with  three  flagella  and  a  large  cytostome.  It  may 
cause  diarrhoea  and  dysentery.  It  has  been  seen  in 
people  from  the  Crimea,  Bahama,  Hawaii  and  West 
Africa. 

Trichomonas  hominis  may  be  found  in  some 
diarrhoea  patients. 

Trichomonas  vaginalis  has  been  found  in  Central 
Africa,  Ceylon  and  Kurope.  Its  name  is  descriptive. 
Its  presence  does  not  necessarily  give  rise  to  symptoms. 

Lamblia  intestinalis  with  its  pear-shaped  body 
carries  three  flagella  from  its  broad  end  and  one  from 
the  narrow  end. 

It  has  been  found  in  the  rabbit,  cat,  dog,  sheep 
and  large  bowel  of  man.  Its  cysts  can  be  found  m 
the  faeces.    Pathological  changes  are  not  severe.    Treatment  is  difficult. 

The  Peucocytozoidae.are  not  found  in  man. 

The  Trypanosomidae  are  dealt  with  under  special  headings. 

The  Herpetomonas  (Leptomonas,  Crithidia)  are  not  found  in  man. 


Trichomonas  iu' 
testinalis  from 
man,  showing  an- 
terior flagella, cyto- 
stomic  depression 
anteriorly,  undula- 
ting  membrane, 
nuclei,  and  axo- 
style.  X  2,500. 
Original. 


6  DISEASES  DUE  TO   PROTOZOA 

The  Leishmania  are  dealt  with  under  the  Leishmaniases. 

The  Histoplasma  capsulatum  is  a  round  or  oval  parasite  enclosed 
in  a  refractile  capsule  with  an  acentral  nucleus  and  chromatic  particles 
causing  an  acute  specific  disease  known  as  Histoplasmosis.  The 
parasite  is  found  in  the  endothelial  cells  of  capillaries  and  smrill  blood- 
vessels in  the  liver,  spleen,  lungs,  intestine  and  lymphatic  glands  as 
well  as  in  the  leucocytes.  It  causes  an  irregular  fever  characterized  by 
disseminated  hyaline  pseudogranulomata  in  the  lungs,  splenomegaly, 
necrotic  areas  in  the  liver,  ulceration  of  the  large  nnd  small  intestine, 
severe  ana?mia,  and  with  it  a  marked  leucopcenia. 

Dr.  Darling  discovered  it  at  Panama  in  igo6. 

Nothing  is  known  as  to  treatment. 

Babesia  has  not  been  found  in  man  with  the  doubtful  exception  of 
Babesia  hominis  in  Spotted  Fever  of  the  Rocky  Mountains  (Manson, 

1903)- 

Sambon    believes   that    Blackwater    Fever    is   caused    by   a    minute 

babesia.     See   "  Blackwater  Fever." 

The  Plasmodidai  pathogenic  to  man  are  dealt  with  under  Malaria. 

Pathogenic  Spiroch^etes  are  dealt  with  under  Relapsing  Fever. 

The  Treponema  pertenue  under  Frambocsia  tropica. 
(3)  Sporozoa. 

(A)  Telosporidia. 

Coccidium  oviforme  (Eimeria  stieda?)  occurring  in  the  liver  and 
bile  ducts  of  rabbits  has  been  found  five  times  in  man.  In  these  cases 
there  were  :  fever,  enlarged  liver  and  spleen,  both  of  which  contained 
coccidia,  the  infection  of  the  spleen  being  probably  via  the  blood- 
stream. 

H^mogregarines,  in  all  probability,  never  occur  in  man. 

(B)  Neosporidia. 

Sarcocystis  tenell?e  bubali  is  common  in  bufifalo  meat  in  Ceylon, 
the  parasites  being  known  as  "milk  nerves,"  which  appear  as  white 
patches  lying  amongst  the  muscle  fibres  of  tlie  tongue,  larynx, 
diaphragm  and  skeletal  muscles.  The  ingestion  of  the  spores  may 
cause  :   Irregular  fever  in  man. 

S.  lindemanni  and  S.  muris  have  been  described  in  man  upon 
several  occasions.  There  are — Regular  fever,  myositis,  sometimes 
necrosis  of  muscle  fibres.  Spores  may  be  found  in  the  blood,  and  the 
parasites  should  be  searched  for  amongst  the  muscle  fibres. 

They  are  found  normally  in  warm-blooded  animals.  In  them  the 
spore  formation  commences  early  and  continues  until  a  large  size  has 
been  attained.  The  spore  has  two  coats,  a  number  of  fibrous  sectors 
dividing  the  spore,  and  remaining  continuous  with  the  inner  coat. 

No  human  has  died  from  the  disease. 


MODES    OF   TRANSMISSION  7 

Sarcosporidiosis  was  proved  in  a  Barbadian  negro;  the  sporozoa 
were  found  in  a  portion  of  the  biceps  muscle  (Darling),  but  the  disease 
aborted  in  three  weeks,  leaving  the  patient  free. 

Rhinosporidium  seeberi  is  similar  to  tlie  above,  but  has  a  well- 
defined  sporoblast.  The  parasite  has  been  obtained  from  nasal  polypi 
and  penile  papilloma  (Ingram).  The  growth  has  a  raspberry  appear- 
ance, with  white  spots  on  a  general  red  background.  The  dots  are 
the  cysts.  The  irritation  of  the  parasite  causes  proliferation  of  the 
mucosa  and  sub-mucosa  of  the  affected  part.  The  source  of  the  infection 
is  unknown. 

The  condition  is  known  as  Rhinosporidiosis. 

It  has  been  seen  in  South  America,  India  and  Ceylon. 

The  treatment  is  to  remove  the  growth  and  cauterize  the  base. 

Balantidium  coli  and  minutum  cause  diarrhoea  and  abdominal  pain 
in  man  (enterocolitis).     See  the  Dysenteries. 
(4)  Ciliata. 

Numerous  forms  of  ciliated  protozoa  existing  in  man  but  not  pro- 
ducing any  symptoms  are  not  dealt  with  here. 

MODES   OF  TRANSMISSION. 

Insects  become  infected  witii  animal  parasites  in  various  ways  :  — 
(i)  Insects  suck  up  parasites  with  the  blood  when  they  are  feeding 
upon  that  medium.     Such  parasites  develop  and  multiply  in  the  insects 
and  are  later  injected  into  man  during  the  act  of  drawing  more  blood. 

(2)  The  development  of  the  parasite  taken  up  with  the  blood  may 
continue  in  the  eggs  of  the  host,  which  process  of  development  is  not 
completed  until  the  eggs  are  hatched.  Young  ticks,  having  developed 
from  an  infected  egg,  may  bite  a  warm-blooded  host  and  infect  him, 
although  it  has  not  previously  fed  on  infected  matter.  This  process 
takes  place  in  the  case  of  the  piroplasma  and  spirochete. 

(3)  Parasites  drawn  up  with  the  blood  may  develop  in  the  alimentary 
tract  of  the  insect  and  infective  sporozoites  may  be  passed  with  the 
feces . 

(4)  Larve  of  the  invertebrate  host  living  in  water  may  become 
infected  directly  by  means  of  their  food.  These  larve  and  their 
ingested  parasites  develop  simultaneously,  so  that  by  the  time  maturity 
of  the  insect  is  reached  the  parasites  are  very  numerous.  Such  parasites 
may  then  be  passed  with  the  feces  and  live  independently,  to  enter 
into  other  larve  later.  Flagella  may  thus  be  transmitted.  This 
method  applies  not  only  to  protozoa,  but  also  to  metazoa  and  bacteria. 

The  following  facts  show  briefly  how  the  most  important  protozoal 
diseases  are  transmitted  :  — 


8  DISEASES  DUE  TO   PROTOZOA 

(i)  The  malarial  parasites,  P.  vivax,  P.  malariie  and  P.  falciparum 
have  their  reservoir  in  convalescents  from  primary  attacks  and  for 
weeks  after  such  attacks;  the  parasites  leave  the  host,  man,  by  blood 
drawn  up  by  blood-sucking  insects;  the  sexual  stages  or  external 
development  of  the  parasite  takes  place  in  some  species  or  anophelines ; 
it  re-enters  man  with  the  saliva  of  the  biting  mosquito. 

(2)  In  Yellow  fever  the  parasite  is  not  known,  but  the  reservoir 
is  the  blood  in  the  early  stages  of  the  disease;  it  leaves  the  host  like 
the  above;  passes  its  external  phase  in  a  mosquito,  Stegomyia  calopus; 
and  re-enters  man  by  mosquito  bites  about  ten  days  after  feeding  on 
infected  persons,  after  which  period  the  mosquitoes  have  become 
infective. 

(3)  In  Dengue  fever  the  parasite  is  not  known ;  its  reservoir  is 
human  blood,  and  is  carried  away  with  the  blood  by  the  Stegomyia 
calopus  or  Culex  fatigans ;  re-infecting  man  by  the  mosquito. 

(4)  In  Trypanosomiasis  the  parasite,  Trypanosome  gambiense  or 
T.  rhodesiense,  has  its  reservoir  usually  in  man  in  the  former  instance 
and  usually  in  wild  game  in  the  latter  case;  it  leaves  the  host  with  the 
blood;  passes  its  external  life  in  the  Glossina  palpalis  or  G.  morsitans ; 
and  re-enters  man  eighteen  days  or  more  after  the  fly  has  fed  on  an 
infected  person  by  biting  and  sucking  blood  in  the  ordinary  way. 

(5)  In  Kala-azar  the  parasites,  Leishman-Donovan  bodies,  prob- 
ably have  their  reservoir  in  man  ;  leave  the  host  in  the  leucocytes  with 
the  blood ;  pass  their  extra-corporal  life  in  bed  bugs,  Cimex  rotundatus, 
and  re-infect  man  by  the  bites  of  these  bugs. 

(6)  In  Relapsing  fever  the  parasite,  Spiroch^ete  recurrentis,  has  its 
reservoir  usually  in  man ;  leaves  the  host  by  the  blood  plasma ;  passes 
its  external  life  probably  in  the  Pediculus,  and  re-infects  man  by  its 
bites. 

(7)  In  African  Tick  fever  the  parasite,  S.  duttoni,  has  its  reservoir 
in  man  or  a  progeny  of  infected  ticks ;  leaves  man  in  the  blood  and 
saliva;  passes  its  external  life  in  the  Ornithodorus  moubata  and  re- 
enters man  by  its  bites. 

(8)  In  SpirochcBtal  diseases,  Yaws,  S^philis  and  some  ulcers,  the 
parasites,  S.  pertenuis  and  S.  pallida,  have  their  reservoir  in  man; 
leave  the  host  by  the  discharges;  have  no  external  development,  and 
re-infect  man  by  contact  usually  with  an  abraded  surface. 

(9)  In  Amoebic  dysentery  the  parasite.  Entamoeba  tetragena,  has 
its  reservoir  in  convalescents  from  the  disease,  leaving  the  host  in  the 
fasces  in  an  encysted  form  ;  further  developing  while  encysted,  in  earth, 
water  or  dust;  re-infecting  man  by  the  mouth  in  water,  milk,  food,  &c., 
contaminated  by  the  parasite. 


RELAPSING   FEVER  9 

RELAPSING   FEVER. 
DEFINITION. 

An  acute  infectious  disease  or  group  of  diseases:  — 

Caused  by  the  SpirochcTtes,  S.  recurrentis,  S.  novyi,  S.  duttoni, 
S.  carteri. 

Transmitted  by  bed  bugs,  body  lice  and  ticks. 

Characterized  by  sudden  onset,  definite  course  (r  to  7  days),  rapid 
subsidence  and  indefinite  relapses. 

HISTORICAL. 

A  relapsing  fever  was  known  to  Hippocrates  in  Thasos,  which  he 
described. 

The  next  notice  of  it  was  by  Rutty  of  the  Dublin  epidemic  in  1770. 

In  1873  Obermeier  published  his  discovery  of  the  causative  spiro- 
ch^ete  during  a  Berlin  epidemic. 

In  1897  Tictin  proved  the  bed  bug  as  a  carrier. 

In  1904  Philip,  Ross  and  Milne  in  Uganda  discovered  that  the  tick 
Ornithodorus  moubata  was  the  carrier  of  the  African  Tick  Fever. 

Dutton  and  Todd  in  the  Congo  confirmed  this,  and  proved  that 
the  parasite  could  pass  into  the  egg  and  larva,  thus  infecting  succeed- 
ing generations. 

Napoleon's  Grand  Army  was  attacked  by  it  in  the  great  retreat 
from  Moscow.  The  allied  Armies  were  affected  by  it  during  the 
Crimean  War,  and  both  armies  suffered  from  it  in  the  Russo-Turkish 
War. 

DISTRIBUTION. 

Relapsing  Fever  is  found  in  Europe,  Asia,  Africa,  North,  Central 
and  South  America,  and  probably  in  Australia. 

The  Relapsing  fever  of  Europe  is  caused  by  S.  recurrentis  or 
obermeieri ; 

The  Relapsing  fever  of  America  is  caused  by  S.  novyi ; 

The  Relapsing  fever  of  Asia  is  caused  by  S.  duttoni ; 

The  Relapsing  fever  of  Africa  is  caused  by  S.  carteri. 

The  number  of  the  spirochaetes  present  in  the  peripheral  blood 
during  infection  is  variable  according  to  the  type  of  parasite;  thus  in 
the  African  type  the  infection  is  light,  in  the  European  type  it  is 
heavy,  and  in  the  Indian  type  it  is  variable. 

The  different  types  will  now  be  considered  seriatim. 

EUROPEAN   RELAPSING   FEVER. 
ETIOLOGY. 

The  causative  organism  is  S.  recurrentis  (obermeieri),  which  is 
found  in  the  peripheral  blood  during  attacks,  but  is  usually  absent 
between  them.     Its  absence  from  the  peripheral  blood  during  apyrexial 


10  DISEASES  DUE  TO   PROTOZOA 

periods  is  due  to  the  formation  of  antibodies  such  as  agghitinins  and 
parasiticidal  substances,  but  some  spiroch^etes  resist  this  attempt  at 
cure  and  cause  a  relapse  when  they  are  in  sufficient  numbers.  Resistant 
types  of  spirochastes  develop  during  and  after  an  attack.  Spiroch^etes 
are  usually  present  in  the  peripheral  blood  from  the  onset  of  the  fever 
until  the  crisis,  then  suddenly  and  totally  disappear,  possiblv  collect- 
ing in  the  spleen.  They  have  never  been  found  in  the  excretions  or 
secretions.  Some  immunity  is  caused  after  an  attack,  but  onlv  for 
that  specific  spirillum.  Gozony  concludes  that  infection  is  possible 
through  the  damaged  skin,  healthy  mucous  membrane  of  the 
alimentary  or  genital  tract,  or  possibly  by  the  conjunctiva}.  It  is 
proved  that  the  parasite  is  carried  by  the  bed  bug,  Cimex  lectularius, 
and  lice  by  direct  inoculation.  The  spiroch^etes  multiplv  by  longi- 
tudinal and  transverse  fission.  They  are  hereditarily  transmitted  from 
adult  to  young  lice,  and  are  thus  maintained  in  nature. 

The  infection  can  be  transmitted  from  mother  to  foetus.  On  this 
point  Nattan-Larrier,    Breinl  and  Kinghorn  conclude  that — 

Both  S.  recurrentis  and  S.  duttoni  have  been  proved  to  transmit 
infection  to  the  foetus  in  80  per  cent,  of  cases,  but  the  number  of 
spirochastes  penetrating  the  placenta  is  not  great ;  this  fact  would 
explain  the  long  incubation,  small  blood  infection  and  short  persistence 
of  the  parasite  in  the  blood  in  these  foetal  infections,  but  their  virulence 
is  not  attenuated. 

When  pregnancy  is  nearing  the  end  there  may  be  a  serious  illness 
with  death  of  the  foetus  in  utero.  No  lesions  of  the  uterus  are  necessary 
to  facilitate  the  passage  of  the  spirochaetes. 

Very  little  immunitv  is  given  to  young  born  of  an  infected  mother. 

INCUBATION. 

Two  to  ten  days,  never  after  the  fourteenth  day,  sometimes  on  the 
same  day. 

SYMPTOMATOLOGY. 

Onset. — This  is  usually  sudden  with  rheumatic-like  pains,  head- 
ache and  constipation,  which  sometimes  precede  the  rigors.  There  is 
severe  frontal  headache,  pains  in  the  back,  limbs  and  epigastrium; 
weakness,  giddiness,  convulsions  in  the  young,  flushed  face,  injected 
conjunctivae,  fever  to  io3°-io4°  F.,  pulse-rate  to  1 10-120,  respirations 
increased,   sometimes  nausea  and  vomiting. 

Course. — The  skin  becomes  yellowish,  hot  and  moist. 

There  is  often  a  rose-coloured  macular  eruption  on  the  thorax^ 
abdomen  and  legs  for  one  or  two  days. 

The  temperature  keeps  up  until  the  eighth  day,  third  to  fourth  day 
in  Serbian  cases. 


EUROPEAN  RELAPSING  FEVER  ix 

There  is  thirst,  nausea  and  vomiting  of  yellow-green  matter. 

Constipation  is  common,  but  diarrhoea  is  rare. 

The  liver  and  spleen  are  enlarged  and  tender. 

The  pulse  is  120  to  140,  but  not  dicrotic.     Respirations  are  48-50. 

Red  cells  and  Hb.  are  diminished. 

There  is  leucocytosis  of  the  polymorphs. 

Spirocha?tes  are  found  in  the  peripheral  blood  and  engulfed  in  the 
leucocytes. 

A  troublesome  cough  is  common  with  rales  and  a  scanty  expec- 
toration. 

Muscle  and  joint  pains  continue  and  cause  sleeplessness. 

Delirium  is  not  uncommon,  stupor  is  rare. 

The  urine  is  febrile  and  often  contains  a  little  albumin. 

Sometimes  herpes  labialis  is  seen.  There  may  be  rose-coloured 
spots  on  the  trunk  and  limbs. 

Crisis. — This  takes  place  on  the  sixth  or  seventh  day,  usually  by 
rigor. 

There  is  a  violent  perspiration  and  sometimes  diarrhoea. 

Epistaxis  is  not  uncommon.  There  is  a  sudden  fall  of  temperature, 
pulse-rate  and  respirations,  then  a  deep  sleep,  followed  by  rapid 
improvement.  Sometimes  there  is  a  dangerous  collapse  at  the  crisis 
with  old  people. 

Intermission. — All  appears  to  be  normal,  but  it  is  the  exception 
for  the  disease  to  end  here.  The  patient  usually  desires  to  leave  the 
hospital.     About  the  fourteenth  day  from  the  onset  there  is  a 

Relapse,  with  rigor  and  severe  symptoms  as  before,  lasting  three 
or  four  days.  The  urine  is  increased,  the  pulse-rate  goes  up,  and  the 
prostration  is  often  marked.  The  termination  is  by  crisis  which  may 
end  the  illness.  If  there  are  more  relapses,  which  is  common,  they 
become  gradually  milder  in  severity.  The  second  relapse  occurs  about 
the  twenty-first  day  from  the  onset,  is  milder,  and  lasts  about  three 
days  as  a  rule. 

Convalescence  is  sometimes  slow. 

COMPLICATIONS. 

Bronchitis,   pneumonia,   dysentery,   diarrhoea,   ha^matemesis. 

Cerebral  haemorrhage,  conjunctival  haemorrhage,  iritis,  irido- 
cyclitis, corneal  ulcers. 

Abortion  during  the  tirst  relapse  is  common. 

Nephritis,  otorrhoea,  neuritis,  parotitis  and  adenitis  are  not  un- 
common. 

Meningism,  paresis  with  spasticity  of  lower  limbs. 

Recurrent  myocarditis,   followed  always  by  death  (van  Hoof). 


12  DISEASES  DUE  TO   PROTOZOA 

DIAGNOSIS. 

In  the  early  stages  one  must  differentiate  it  from  Malaria,  Typhoid, 
Typhus,  Yellow  fever.  Seven-day  fever  and  Influenza.  The  following 
are  the  main  points  to  watch  :  — 

(i)  For  spirochaetes  in  the  blood. 

(2)  Malarial  parasites  in  the  blood. 

(3)  Agglutination  ;  add  a  drop  of  suspected  serum  to  a  drop  con- 
taining spirochastes,  mix,  cover  with  cover-glass,  seal,  incubate  at 
37°  C.  for  half  an  hour.  Clumping  of  spirocha?tes  into  non-motile 
masses  is  positive. 

(4)  Typhoid  by  absence  of  leucocytosis. 

(5)  Typhus  by  absence  of  spirochaetes,  agglutination  test  and 
presence  of  rash. 

(6)  Yellow  fever  by  black  vomit 

(7)  Seven-day  fever  by  slow  pulse  and  absence  of  spirocha?tes. 

(8)  Influenza,  from  a  mild  attack  of  Relapsing  fever,  not  easy  to 
differentiate  apart  from  absence  of  spirochaetes. 

Relapsing  fever  may  co-exist  with  Malaria,  Small-pox,  Measles, 
Plague. 

Diphtheria  and  Scurvy  after  famines. 

PROGNOSIS. 

This  is  good.  Mortality  4  per  cent,  in  Europe,  14  per  cent,  in 
Egypt  (Sandwith). 

Marked  jaundice  is  bad. 

Pregnant  women  usually  abort. 

Death  may  be  caused  by  :    Toxaemia  during  the  first  attack  ; 

collapse  during  the  intermission  ; 

complications  intervening. 

TREATMENT. 

Rest  in  bed  is  essential. 

Salvarsan,  neosalvarsan,  galyl  or  kindred  preparations  are  specific, 
and  should  be  given  intravenously  or  intramuscularly;  the  former  is 
better.  These  drugs  have  revolutionized  the  treatment  of  these  fevers. 
One  should  begin  with  small  doses  as  some  patients  stand  them  badly, 
say  with  0*30  grm. 

Relieve  pains  with  salicylates,   aspirin,   antipvrin  and  quinine. 

Opium  or  morphia  may  be  necessary. 

Vomiting  with  ice,  champagne,  bismuth  mixture,  morphia  and 
codeine. 

Epigastric  pains  with  fomentations  sprinkled  with  opium  tincture. 

Cough  by  codeine  and  heroin  or  expectorant  mixture. 


AMERICAN    RELAPSING    FEVER  13 

Constipation  by  laxatives  and  enemata. 

High  temperature  by  cool  sponging. 

Give  appropriate  feeding  during  the  intermission. 

A  serum  has  been  promised. 

PROPHYLAXIS- 

Keep  bugs,  lice  and  biting  insects  away  from  the  patient. 
Wooden  bedsteads  should  be  abolished  and  iron  ones  substituted. 
Practice  the  strictest  cleanliness,   disinfect  clothing,   houses,  &c. 
Doctors,   nurses,   hospital   attendants  and   laundry   hands  are  very 
liable  to  attack. ~    -        _        . 

MORBID  ANATOMY. 

There  is  an  enlargement  of  the  spleen,  five  or  six  times  its  normal 
size,  and  may  weigh  five  or  six  pounds.  On  section  it  is  dark  coloured^ 
soft  with  enlarged  follicles,  showing  congestion  and  a  cellular  increase. 
There  may  be  minute  abscesses  and  wedge-shaped  infarcts. 

The  liver  is  enlarged  up  to  five  pounds  in  weight,  the  lobules  are 
poorly  defined  with  cloudy  swelling,  fatty  infiltration  and  leucocytic 
infiltration  into  the  portal  system. 

The  kidneys  are  enlarged,  congested,  cloudy  swelling,  and  fatty 
degeneration.     The  stomach   is  congested. 

The  heart  is  soft  and  flabby. 

The  bronchi  are  congested,  frothy  mucus,  lungs  hypostatic  con- 
gestion. 

The  brain  is  congested. 

All  the  viscera  may  be  stained  vellow  with  bile. 

The  bone  marrow  is  hyper^emic. 

Sometimes  there  is  a  submucous  petechias. 

AMERICAN    RELAPSING   FEVER. 

It  is  present  in  North,  Central  and  South  America.  In  the  two 
latter  instances  the  fever  is  similar,  but  the  spiroch^ete  has  not  yet 
been  definitely  classified. 

ASIATIC    RELAPSING    FEVER. 

The  causative  parasite  is  the  S.  carteri.  The  carrier  is  unknown. 
The  disease  has  long  been  endemic  in  India,  commonest  in  the 
Bombay  Presidency.  Infected  bugs  can  convey  the  disease  to 
monkeys,  but  Rogers  suspects  mosquitoes  as  human  carriers,  while 
Mackie  favours  Pediculus  capitis. 

The  spirochcetes  are  found   in   the  blood  during  the  acute  attack, 


14 


DISEASES  DUE  TO   PROTOZOA 


becoming  more  numerous  towards  the  crisis,  after  which  they  com- 
pletely disappear.  They  are  not  always  seen  during  the  relapse,  and 
may  not  be  found  at  all  during  a  typical  attack.  On  the  other  hand, 
they  have  been  known  to  be  so  numerous  that  the  circulation  of  the 
blood  has  been  hindered  and  a  dusky  lividity  caused  (Carter). 

Rigors  are  usually  absent  in  this  form. 

After  the  crisis,  instead  of  feeling  better,  there  is  more  often 
collapse,  sometimes  resembling  that  in  a  cholera  patient.  There  is 
much  debility. 


TIME     MCMCMEMCMCMCMCMEMCM^MCMtMCMCMCHCMCMtMtMCMC 

r* 

,I'_L,jA  X^A                1                                               f\    IlZ^A    ' 

:    t     "^-i  I-               J  v4LV  ^^  ~ " 

'"  ,'-            \                   ^ 

'"  +            > 

_.-_U 1 J._A_Ac-^ 4- 

:!  t==~=  :::::ij^?  +!:  :!:!_:::::""s^'- 

M    -        ±       ^t        _     __ 

Relapsing  fever.     Indian. 


In  16  per  cent,  of  cases  there  is  a  sudden  rise  of  temperature  during 
the  first  intermission  period  when  spirochaetes  are  not  found  in  the 
blood. 

Haemorrhage  from  the  stomach  and  intestines  is  more  common  than 
in  the  other  forms.     Parotitis  is  present  in  10  per  cent,  of  cases. 

Bile  in  the  urine  is  scanty. 

Epistaxis  occurs  in  from  10  per  cent,  to  15  per  cent,  of  cases. 

Vomiting  of  bile  occurs  frequently,  70  per  cent,  to  80  per  cent. 

Diarrhoea  is  present  in  10  per  cent. 

Maniacal  symptoms  are  known. 

The  first  relapse  occurs  about  the  fourteenth  day  from  the  onset, 
seventh  day  from  the  intermission.  The  second  intermission  may  last 
longer  than  the  first  ten  days.  Second  relapses  are  common,  but  the 
liver  does  not  so  markedly  enlarge,  and  the  crisis  is  not  so  well  marked. 

A  third  relapse  may  occur  after  a  secondary  intermission  of  ten  to 
seventeen  days. 

The  percentage  of  relapses  to  be  expected  can  be  seen  from  the 
following  table  :  — 

With  one  relapse,  49*2  per  cent. 

With  two  relapses,  20  per  cent. 

With  three  relapses,  5  per  cent. 

With  four  relapses,  2  per  cent.  ' 

In    some    cases    the   attacks    may    be    more    prolonged,    irregular, 


AFRICAN    RELAPSING   FEVER 


15 


ending  by  lysis  and  ^vilh  marked  jaundice,  70  per  cent,  to  80  per  cent, 
of  cases. 

The  mortality  is  higher  than  in  the  others,  18  per  cent.  In  Bombay, 
30  per  cent,  to  40  per  cent.,  according  to  Daniels.  Sudden  death  from 
heart  failure  is  common. 

Heart  stimulants  should  be  given  and  collapse  avoided  by  camphor, 
ether,   strychnine,  hot  bottles,  blankets,  &c. 

AFRICAN  RELAPSING  FEVER  (African  Tick  Fever). 

The  causative  organisms  are  S.  duttoni  and  S.  recurrentis 
(obermeieri)  in  West,  East  and  Central  Africa. 

The  carriers  are  Ornithodorus  moubata  and  Pediculus  humanus. 

The  disease  is  present  in  Angola,  Congo  State,  Uganda,  German 
East  Africa,   Portuguese  East  Africa  and  the  Zambesi  Valley. 


C 


Spirochoeia  duttoni,  a,  blood  form  showing 
slight  membrane  ;  &,  granules  or  coccoid  bodies 
clearly  formed  within  the  organism  ;  c,  beginning 
of  extrusion  of  coccoid  bodies  in  the  tick.  (After 
Fantham.) 


The  infection  is  by  small  spiroch^etal  chromatin  segments,  which 
come  from  the  lumen  of  the  gut  of  the  tick  and  contaminate  the  wound 
made  by  it.  The  chromatin  segments  pass  into  the  wound  as  a  result 
of  the  regurgitation  of  the  gut  contents  or  the  Malpighian  secretion, 
and  also  as  a  result  of  its  faeces  contaminating  the  abraised  surface. 

Scratching  after  a  tick  bite  is  said  to  cause  sufficient  abrasion  for 
the  parasites  to  pass  through  the  skin  and  cause  the  infection. 


i6  DISEASES  DUE  TO   PROTOZOA 

There  is  often  some  local  inllammatory  reaction  at  the  site  of  the 
bite.  In  this  variety  there  is  more  vomiting  and  diarrhoea  with  blood- 
streaked  stools. 

The  spiroch^etes  are  very  sparse  in  the  blood,  as  compared  with  the 
other  varieties,  but  heavy  infections  have  been  met  with  in  Arabia. 

On  the  second  day  of  the  illness  there  is  restlessness,  thirst,  splenic 
pain,  cough,  the  temperature  has  a  morning  fall  without  any  relief  of 
the  symptoms,  and  an  evening  rise.     There  may  be  delirium. 

The  Hver  does  not  enlarge,  but  the  spleen  does. 

There  is  polychromatophile  degeneration  of  the  red  cells  and  a 
marked  increase  in  the  number  of  blood  platelets. 

After  the  third  or  fourth  day  there  is  a  crisis  preceded  by  a  pseudo- 
crisis. 

Relapses  are  very  common,  five  to  eleven,  lasting  three  days  each, 
and  spreading  over  a  month  or  more.  All  crises  are  preceded  by 
pseudo-crises. 

In  the  relapses,  oedema  of  the  eyelids  is  a  common  feature. 

Iritis  is  a  common  complication. 

There  is  often  an  abrupt  violent  delirium  (Porot). 

Some  consider  that  there  is  a  mild  and  a  severe  form  of  the  disease. 

The  mortality  is  not  known,  but  it  is  generallv  low. 

A  rapid  fall  of  temperature  without  improvement  of  the  svmptoms 
usually  indicates  the  approach  of  death. 

All  Europeans  should  encamp  20  to  30  metres  away  from  native 
huts,  rest  houses  or  caravans.  The  bed  should  be  well  above  the 
ground,  and  a  good  mosquito  net  used  with  its  lower  ends  well  tucked 
under  the  mattress. 

In  North  Africa. 

In  North  Africa  the  causative  organism  is  S.  berbera,  as  a  rule. 
It  is  probably  spread  by  lice.     It  is  common  in  Algeria,   Egypt, 
Tripoli  and  Tunis. 

The  surgeons  of  Napoleon's  Army  noticed  the  disease. 
The  incubation  is  believed  to  be  about  twelve  days. 
The  fever  reaches  its  height  during  the  first  twenty-four  hours. 
The  spleen  and  liver  enlarge,  but  jaundice  is  generally  absent. 
Vomiting  is  common,  but  not  diarrhoea. 

Urethral  Spirochcvtosis. 

^lacfie  found  a  case  of  acute  urethritis  on  the  Gold  Coast  due  to 
spirochcete  infection.  The  temperature  was  slightly  raised  and  joint 
pains  were  troublesome. 

The  name  S.  urethras  was  proposed  for  the  parasite. 


SFIROCH.WrOSIS    ICTERO  HEMORRHAGIC  A  17 

SPIROCH.^TOSIS    ICTEROH.EMORRHAGICA    (WEIL'S 

DISEASE). 
DEFINITION. 

An  infective  febrile  jaundice  caused  by  S.  icleroha^morrhagica  and 
characterized  by  pyrexia,  marked  prostration,  jaundice,  albuminuria 
and  haemorrhages. 

HISTORY. 

1849,  Larrey  first  described  it.  After  him  were  several  other  French 
workers  prior  to  Weil  in  1886. 

1914,  Inada  and  Ito  in  Japan  found  the  causative  parasite. 

1916,  Martin  and  Pettit  found  the  disease  to  be  present  amongst  the 
French  troops  in  Flanders. 

DISTRIBUTION. 

There  are  widespread  epidemics  in  the  United  States. 
The  disease  is  epidemic  and  endemic  in  Japan. 
It  is  also  found  in  India,  Africa,  the  Near  East,  and  amongst  the 
French  troops  in  Flanders  and  on  the  Italian  front. 

AETIOLOGY. 

The  causative  organism  is  the  S.  icteroh^emorrhagicae. 

They  have  been  recovered  from  the  blood  and  urine;  from  the 
former  during  the  first  days  of  the  disease,  and  the  latter  from  the 
ninth  to  the  fifteenth  day.  They  disappear  at  the  end  of  the  fifth  week. 
They  have  also  been  found  in  the  kidneys  of  the  field  rat,  which  animal 
is  now  held  to  be  a  reservoir  host  for  the  spiroch^etes. 

An  immune  body  has  been  found  during  the  disease  in  the  blood 
which  is  said  to  destroy  and  dissolve  the  spiroch^etes.  It  is  very 
difiticult  to  find  them  at  all  in  some  severe  cases  of  the  disease. 

Sera  have  been  suggested  for  prophylaxis  and  treatment. 

Infection  is  probably  by  infected  rats,  passing  infected  urine  and 
fouling  the  water  and  food  such  as  could  so  easily  happen  in  the 
trenches  in  Flanders. 

SYMPTOMATOLOGY. 

The  incubation  is  doubtful,  probably  six  to  eight  days. 

The  onset  is  sudden. 

There  are  :  conjunctival  congestion,  headache,  general  body  pains, 
bilious  vomiting,  slight  swelling  of  lymphatic  glands,  gastric  disturb- 
ance, epistaxis  (17  per  cent.),  fever,  ioo°-i04°  F.,  lasting  ten  to  four- 
teen days,  jaundice  (60  per  cent.) — this  comes  on  the  fourth  or  fifth 
day  when  present — albuminuria,  constipation,  liver  and  spleen  slightly 
enlarged.  Marked  general  weakness  and  prostration. 
2 


i8  DISEASES  DUE  TO   PROTOZOA 

Herpes  labial  is  (42  per  cent.),  which  becomes  hccmorrhagic. 

In  severe  cases  liiere  may  be  marked  lic-umorrliages  under  ihe  skin 
and  from  the  mucous  membranes. 

There  is  sometimes  a  secondary  fever. 

Some  workers  describe  a  meningitis  and  claim  lo  have  found  tlie 
organism  in  the  C.S.F.  (Costa  and  Troisier). 

The  attack  lasts  from  ten  days  to  three  weeks. 

The  attack  may  be  so  slight  that  few  of  the  above  svmploms  may 
be  present,  while  in  severe  infections  all  may  be  present  and  sudden 
death  caused  by  rectal  haemorrhages. 

In  some  cases  the  spiroch^etes  seem  to  concentrate  in  the  duodenum. 
There  is  inflammation  of  the  mucous  membranes  and  of  the  ])aj)il]a  of 
Vater.  The  swelling  causes  obstruction  of  the  bile  flow  along  the 
common  duct  and  jaundice  results. 

In  some  cases  the  swelling  of  the  affected  mucous  membranes  causes 
mechanical  obstruction  of  the  bile  in  the  liver  itself,  follow^ed  by 
jaundice,  or  the  swelling  may  be  so  slight  that  obstruction  does  not 
exist  and  jaundice  is  not  seen.  In  any  case  the  jaundice  is  not  due 
to  an  increased  formation  of  bile. 

PROGNOSIS. 

On  the  whole  this  is  good,  but  marked  haemorrhages  are  always  bad. 

The  mortality  is  under  6  per  cent.  On  the  Trentino  and  Isonzo 
fronts  it  was  only  0*55  per  cent.  (361  cases). 

Some  cases  are  so  slight  that  only  an  inoculation  of  guinea-pigs  will 
enable  one  to  make  a  diagnosis  at  all. 

DIAGNOSIS. 

The  spirochcCte  can  be  recovered  from  the  urine  after  the  lenih  day, 
but  it  is  always  difficult  to  find  it  even  in  centrifuged  blood. 

An  inoculation  of  a  guinea-pig  is  preferable. 

Localized  symptoms  will  exclude  Gallstones  and  Cholecystitis. 

Blood  cultures  and  Widal's  reaction  will  exclude  Typhoid  and 
Paratyphoid. 

The  spirochaetes  can  now  be  grown  with  comparative  ease,  hence 
as  the  sera  of  convalescent  patients  cause  clumping — agglutination 
— 'of  the  spirochastes,  we  have  an  important  diagnostic  test. 

Severe  forms  of  trench  fever  cannot  be  diagnosed  from  this  disease 
in  the  slighter  attacks  when  no  jaundice  is  present. 

Acute  yellow  atrophy  is  not  easy  to  exclude  in  some  cases  because 
we  do  not  know  the  cause  of  it.  It  is  suggested  that  one  form  of  it 
may  be  caused  by  this  spirochaete. 


NOTES   ON  TICKS  19 

TREATMENT. 

As  for  Relapsing  fever. 

Immune  horse  serum,  three  doses  of  10  cc.  each  in  the  first  twenty- 
four  hours  (Inada). 

Destroy  all  rats,  especially  those  that  are  apt  to  foul  water  or  food. 

Much  of  our  knowledge  may  have  to  be  revised  and  the  above 
modified  as  we  learn  more  about  the  disease. 

NOTES  ON  TICKS. 

Ticks  belong  to  the  Order  of  the  Acarina,  of  which  they  are  the 
largest  specimens,  always  visible  to  the  naked  eye,  and  the  females 
invariably  larger  than  the  males,  some  of  the  latter  when  engorged 
with  blood  being  nearly  half  an  inch  long. 

They  differ  from  insects  by  having  four  pairs  of  legs  and  in  having 
the  three  parts  of  the  body,  thorax  and  head  fused  into  one  un- 
articulated  mass. 

After  impregnation  the  female  attaches  herself  to  the  host,  becomes 
enormously  distended  with  blood,  drops  off,  hides  herself,  deposits  her 
eggs  by  thousands  within  two  to  ten  days  after  leaving  the  host.  After 
two  to  three  weeks  the  eggs  are  hatched,  the  forthcoming  larvae 
resembling  minute  moving  grains  of  sand,  with  three  pairs  of  legs,  but 
no  sexual  orifice.  The  larva  attaches  itself  to  its  vertebrate  host,  grows, 
moults,  becomes  a  nympha  with  four  pairs  of  legs,  and  a  pair  of 
stigmata  behind  the  hindermost  pair  of  legs. 

It  moults  thrice  more  and  becomes  adult.     Then  the  sexes  unite. 

After  fertilization  the  male  dies,  but  the  female  seeks  blood. 

If  blood  cannot  be  found  the  female  can  fast  for  weeks,  months  or 
years,  until  blood  can  be  found. 

The  two  families  of  ticks  are  :  (i)  The  Ixodid^e,  e.g.,  Ornithodorus 

moubata. 
(2)  Agarsidse,  e.g.,  Argas  persicus. 

The  former  example  transmits  the  spiroch^etes  of  African  Tick 
Fever,  and  the  latter  of  Miana  disease,  &c. 

Ticks  are  transmitters  of  important  animal  diseases  due  to  Spiro- 
chastas  and  Babesise. 

Ornithodorus  mouhata. 

It  is  found  throughout  Tropical  Africa. 

The  body  is  flattened,  oval  in  outline,  and  greenish-brown  in  colour. 

The  integument  is  hard,  leathery,  covered  with  closely  set 
tubercles  lined  by  grooves.  It  lives  in  native  huts,  hides  during  the 
day  in  cracks  of  walls,  floors,  thatched  roofs,  and  is  very  active  during 
the  night. 


20 


DISEASES  DUE  TO   PROTOZOA 


It  attacks  man  and  beast,  feeds  slowly;  the  victim  must  be  asleep 
for  it  to  receive  a  good  feed  which  requires  two  to  lliree  hours. 

It  deposits  its  eggs  in  batches  of  50,  70,   100;  these  hatch  in  about 


Oniithodonis  vioitbata.     a.  Ventral  aspect ;    />,  dorsal  aspect ;  c,  lateral  aspect 
between  second  and  third  pair  of  legs. 


twenty  days.  The  larval  stage  is  practically  omitted  in  this  variety. 
After  about  thirteen  days  the  eggshell  splits,  also  the  larval  skin,  and 
an  eight-legged  nymph  throws  off  both  covers  simultaneously. 


FRAMBCESIA    TROPICA 


21 


This  tick  is  commonly  found  along  the  lines  of  travel,  e.g.,  rest 
houses,  caravanserai,  &c.  It  may  be  carried  long  distances  in  bedding, 
mats,  porters'  cloths,  &c. 

The  natives  protect  themselves  by  applving  cow  dung  to  the  floors 
and  walls  of  their  houses  and  by  smoking  the  thatch. 

Pyrethrum  powder  is  good  when  placed  between  the  sheets.  A  little 
sprinkled  down  the  backs  of  porters  is  a  good  measure. 

A  night  light  is  a  protection. 

Argas  pcrsicHS. 

This  tick  is  in  shape  a  flattened  oval,  yellowish  green  or  red  in 
colour,  spotted  on  the  back  with  many  white  granulations;  its  legs 
are  a  pale  yellow,  and  the  whole  insect  is  much  smaller  than  the  one 
described  above. 


Mouth-parts  of  Ixodes. 


Mouih-parts  of  Rhipicephalits 


It  is  found  in  Persia,  Syria,  Turkestan,  Russia,  China,  Algeria  and 
Cape  Colony. 

It  attacks  poultry  and  humans. 

Its  habits  are  those  of  O.  moubata. 

In  Persia  it  may  so  infest  villages  that  the  inhabitants  may  be 
driven  out  of  it. 

FRAMBCESIA  TROPICA  (YAWS). 

DEFINITION. 

A  tropical,  specific,  infectious  and  contagious  disease  due  to  the 
Treponema  pertenuis,  characterized  by  a  yellow-tipped,  granulomatous 
eruption. 

DISTRIBUTION. 

Originally  it  was  purely  an  African  disease,  now  it  is  widely 
spread. 


22 


DISEASES  DUE  TO   PROTOZOA 


Africa. — Tripoli,  Sudan,  ^^>st  Coast,  Congfo  State,  Angola, 
Uganda,  Rhodesia  and  Madagascar. 

Asia. — Malay  Peninsular,  Assam,  Upper  Burmah.  Siani,  Java, 
Batavia,  Philippines  and  Ceylon.  In  Ceylon  the  average  admitted  per 
annum  over  lo  years  was  3,500. 

America. — West  Indies,  British  Guiana,  \>nezuela,  Colombia, 
Brazil.     Some  of  the  Southern  United  States. 

Australia.— North  Australia,  Samoa,  New  Hebrides,  Xew  Cale- 
donia, Fiji,  New  Zealand  and  Tasmania. 

THE  CAUSATIVE  AGENT. 

The  organism  is  a  spirillum,  the  Treponema  perlenuis  (Castellani, 
I905)>  18  to  20 /J,  long,  with  six  to  twentv  fine  uniform  coils  as  shown 
by  Leishman's  stain  (for  five  minutes,   tlien  with  water  admixed  and 

stained  for  one  to  four  hours).  It  is  more 
difficult  to  stain  than  T.  pallidum;  the 
difference  between  the  two  must  be  based 
on  biological  tests. 

Its  presence  is  constant  in  the  primary 
lesion  or  '"  mother  yaw  "  and  in  the  un- 
broken papules  of  the  general  eruption. 
It  is  also  found  in  the  spleen,  lymphatic 
glands  and  bone  marrow.  It  has  not  yet 
been  seen  in  the  blood,  but  its  presence 
is  certain,  because  when  monkeys  are 
injected  with  blood  from  an  infective 
person  it  will  develop  typical  yaw  lesions. 
It  has  not  been  found  in  the  C.l^.  fluid  or 
the  tertiary  lesions. 


Treponema  fericuiic.     (After 
Castellani  and  Chalmers.) 


Multiple  infection  of  the  ulcers  is  very  speedy 


HISTOPATHOLOGY. 

The  surface  epithelium  is  greatly  thickened  over  the  site  of  the 
papules.     The  corium  is  the  site  of  a  marked  oedema. 

There  is  an  infiltration  by  millions  of  plasma  cells;  as  a  matter  of 
fact,  there  is  nothing  else  (Macleod). 

There  is  no  perivascular  mononuclear  infiltration  as  in  Syphilis, 
or  any  endothelial  proliferation  in  the  vessel  walls. 

Giant  cells  are  absent,  but  they  are  present  in  syphilitic  lesions. 

A  well-marked  hyperkeratosis  is  seen. 

The  parasite  is  chiefly  found  in  the  epithelial  layers  (after  Leish- 
man's stain). 


FRAMBCESIA    TROPICA  23 

SYMPTOMATOLOGY. 

■  The  symptoms  last  six  to  twelve  months,  frequently  longer. 

Three  stages  have  been  described  :  — 

The  Primary  Stage. — The  primary  lesion  or  mother  yaw. 

The  Secondary  Stage. — The  characteristic  g'eneral  granulomatous 
eruption. 

The  Tertiary  Stage. — The  deep-seated  ulcerations  and  gummatous- 
like  nodules. 

These  divisions  are  very  arbitrary. 

INCUBATION. 

This  is  from  two  to  nineteen  weeks,  but  may  be  absent. 

PRODROMATA. 

Malaise,  rheumatoid  pains,  headache  and  irregular  temperature,  but 
these  may  be  absent. 

THE  PRIMARY  STAGE. 

The  primary  lesion  occurs  at  the  seat  of  inoculation,  and  is  nearly 
always  extragenital  on  the  mammas  or  hip. 

At  first  there  is  a  papule  the  size  of  a  split  pea,  in  seven  days  it 
becomes  moist,  develops  a  yellow  crust,  other  smaller  ones  coalescing 
with  it.  The  crust  breaks  down,  and  an  ulcer  remains  with  clean-cut 
edges  and  a  granulating  base.  This  may  heal,  leaving  a  white,  later, 
pigmented  scar,  or  it  may  become  a  bare  granulomatous  mass.  It  is 
often  painful  at  first,  but  is  never  indurated. 

The  proximal  glands  may  be  enlarged,  but  do  not  suppurate. 

This  mother  yaw  may  develop  on  an  old  ulcer,  insect  bite  or  wound. 

The  smallest  abrasion  is  sufficient  to  afford  an  entrance  to  the  virus. 

The  mother  yaw  is  usually  still  present  when  the  secondary  eruption 
appears. 

The  duration  of  the  primarv  yaw  is  a  few  weeks  to  a  few  months. 

THE  SECONDARY  STAGE. 

From  one  to  three  months  after  the  appearance  of  the  primary  lesion 
there  may  be  malaise,  headache,  pains  in  the  bones,  joints  and  muscles. 

Pin-head  papu^les  then  appear,  commonl}-  on  the  limbs  and  face, 
but  frecjuentlv  over  the  whole  body;  these  soon  show  a  yellow  crust. 
Some  disappear,  others  coalesce,  and  others  increase  in  size,  forming 
large  nodular  masses.  The  vellow  crusts  conceal  a  yellowish  fungoid 
granular  mass  secreting  a  thin,  slightly  purulent  fluid. 

These  ulcerations  often  form  rings  about  the  mouth  and  anus, 
enclosing  good  skin. 

After  several  months  the  secondary  eruption  diminishes  and  hyper- 
keratosis sets  in,  when  the  papules  become  hard  and  warty. 


24  DISEASES  DUE  TO   PROTOZOA 

Most  of  the  lesions  usually  dry  up  within  six  months  (three  to  six 
months  in  children)  and  disappear.  In  some  cases  the  lesions  may 
persist  for  years,  in  other  cases  the  eruption  may  reappear  every  few 
months.     Each  granuloma  lasts  about  two  months. 

The  ofifensive  sour  odour  given  off  is  probably  due  to  the  secondary 
infection. 

The  eruption  is  seldom  painful  except  when  it  attacks  the  palms 
of  the  hands  and  soles  of  the  feet,  when  the  pain  may  be  considerable. 

The  eruption  may  attack  the  margins  of  the  nails,  when  the  latter 
may  become  hard,  brittle,  thick,  and  finallv  be  shed. 

White  patches  may  peel  off  the  palms  and  soles,  thus  simulating 
syphilitic  psoriasis. 

The  centre  of  the  papules  may  fall  out,  leaving  a  pitted  appearance 
which  may  persist  for  years. 

Fever  is  common  and  is  intermittent  or  remittent  in  type,  but  it 
only  occurs  prior  to  the  secondary  eruption. 

The  cervical  and  inguinal  lymphatic  glands  often  enlarge,  become 
hard,  but  do  not  suppurate. 

Joints  sometimes  become  acutely  painful  and  swollen  simulating 
rheumatism,  but  sodium  salicylates  are  useless.  As  a  rule  no  fever 
accompanies  this  condition. 

Periostitis  is  common  and  often  affects  the  digital  phalanges. 

Contractures  of  the  flexors  of  the  forearm  may  become  permanent. 

Neuritis  and  neuralgia  pains  occur  frecjuentlv. 

Hyperidrosis  is  often  limited  to  the  face,  hands  and  feet. 

Anaemia  is  common  but  is  not  severe,  from  three  to  four  millions. 

THE  TERTIARY  STAGE. 

This  may  not  develop ;  some  denv  its  existence  altogether.  Daniels 
affirms  it  in  Fiji  cases. 

Gummatous  nodules  and  deep  ulcerations  may  follow  the  secondary 
eruption  after  several  years.  On  the  other  hand,  they  may  not  ensue 
at  all. 

When  the  skin  is  affected  the  ulcers  are  rounded  or  irregular  in 
outline,  with  very  thick  and  undermined  edges  and  a  granulating  base. 
There  may  be  painful  nodes  under  the  periosteum  of  the  ribs  or 
sternum.  vSome  cases  show  a  chronic  periostitis  which  alters  the  shape 
of  the  bones.  Bahr  has  described  acute  and  chronic  periostitis, 
osteitis,  epiphysitis,  synovitis,  ulceration  and  gangosa.  There  may 
be  ulcerations  about  the  nasal  bones  resulting  in  rhinopharyngitis 
mutilans. 

Internal  affections  have  not  yet  been  described. 


FRAMBCESIA    TROPICA 


Late  Manifestations. 

Harper,  in  Fiji,  where  syphilis  is  said  to  be  absent,  affirms  that 
tabes,  general  paralysis,  aneurism  and  gangosa  are  late  manifestations 
of  yaws. 


COMMUNICABILITY. 

The  disease  is  not  hereditary.  Two-thirds  of  the  patients  get  it 
before  puberty.  Parents  are  infected  from  their  children  more  than 
children  from  their  parents,  as  a  result  of  the  child  suckling,  when  the 
mother  will  have  the  primary  yaw  on  the  nipple  or  breast  and  as  a  result 
of  the  child  being  carried  astride  the  hip,  when  the  primary  yaw  will 
appear  in  that  position. 

Infection  is  by  direct  contact;  a  damaged  surface  is  necessary. 

Insects  may  carry  the  disease,  for  they  eagerly  crowd  on  the  open 
sores  and  suck  the  secretion  which  may  be  deposited  later  upon  the 
damaged  skins  of  other  people  (Robertson). 

The  mortality  is  low,  2*5  per  cent,  in  treated  cases,  but  the  working 
capacity  is  much  reduced. 

Immunity  is  usually  afforded  after  the  first  attack. 

The  habits  of  the  people  predispose  them  to  the  disease,  the  hand- 
ing round  of  chopsticks  and  water-pipes  from  mouth  to  mouth  and  the 
employment  of  sleeping  mats  common  to  all. 


-'6  DISEASES  DUE  TO   PROTOZOA 

DIAGNOSIS. 

From  Syphilis. — Syphilitic  patients  may  contract  it  and  the  reverse. 
Monkeys  inoculated  with  yaws  do  not  acquire  immunity  against 
syphilis. 

Syphilis  is  worldwide  in  its  distribution,  hut  yaws  is  limited  to 
certain  tropical  regions. 

In  Samoa,  syphilis  was  unknown  prior  to  1880,  but  yaws  has  been 
endemic  there  ever  since  the  people  have  been  known. 

In  British  Guiana  yaws  has  recently  disappeared,  but  svphilis 
remains  (Daniels). 

The  primary  Icsicm  is  usually  extragenital   in   \-aws. 

Pruritis  is  usually  well-marked. 

The  eruption  is  nearly  always  papular,  becoming  granulomatous. 
It  is  not  hereditary. 

There  is  no  thickening  of  the  blood-vessel  walls  so  characteristic 
in  syphilis. 

There  is  a  marked  diffuse  plasma  cell  infiltration  of  the  granulomata. 

Giant  cells  are  absent  in  yaws  but  present  in  svphilis. 

The  consensus  of  opinion  goes  to  show  that  yaws  is  not  identical 
with  syphilis,  although  the  morphological  similarity  between  the  causal 
agents  of  both  diseases  is  a  very  strong  one.  The  same  argument 
applies  to  Tuberculosis  and  Leprosy. 

From  Verruga  Peruviana. — This  disease  is  limited  to  certain  valleys 
of  the  Andes  at  an  elevation  of  3  feet  to  10,000  feet. 

It  has  a  high  mortality,  30  per  cent,  to  40  per  cent. 

It  has  a  severe  fever  of  long  duration. 

The  eruption  attacks  the  mucous  membrane,  which  bleeds  readily. 

TREATMENT. 

Salvarsan,  neosalvarsan,  galyl  and  kindred  preparations  act  very 
quickly,  but  they  may  fail  to  effect  a  cure  in  old  tertiary  cases.  Neo- 
salvarsan is  better  than  salvarsan  because — 

It  dissolves  more  readily  in  water ; 

It  gives  a  neutral  reaction  ; 

It  is  less  toxic  and  better  tolerated  ; 

It  can  be  given  intramuscularly  and  intravenously. 

The  average  single  dose  for  men  is  o"6 — 0*75  grm. 
,,  ,,  ,,  women,  0*45 — o"6  grm. 

,,  ,,  ,,  children,   0-15— 0-3  grm. 

More  than  o'q  grm.  should  not  be  given  in  any  case. 

Intravenously. 

25  c.c.  of  freshly  distilled  water  are  required  for  each  o"i5  grm. 
Some  give  neosalvarsan  and  galyl  concentrated,  such  as  when 


THE   DYSENTERIES  27 

o"45 — o"6  gmi.  is  dissolved  in  10  c.c.  of  sterile  distilled  water. 

075— o'9       M  -  15     M  ,,  „  >, 

The  median  basilic  vein  is  usually  chosen. 

Intramuscularly. 

Inject  into  the  buttocks  5  c.c.  of  a  ^  per  cent,  solution  of  novocain. 

Leave  the  cannula  in  situ,  and  after  a  few  minutes  inject  the  neo- 
salvarsan  through  it.  For  each  o'i5  grm.  use  3  c.c.  of  freshJN-  distilled 
water  in  making  the  solution. 

Doses  are  prepared  in  sealed  tubes  containing  o'i5,  0*3,  0*45,  o'6, 
075  and  o'9  grm. 

Add  the  contents  of  the  sealed  tube  to  a  sterile  saline  solution 
o'4  per  cent,  at  room  temperature. 

Well-boiled  sterile  tap  water  may  be  used. 

Inject  immediately  and  aseptically  at  a  temperature  not  above 
680— 720  p. 

Sufficient  should  not  be  prepared  for  several  patients  at  the  same 
time.  Neosalvarsan  must  not  be  reheated.  If  any  remains  over  it 
should  be  thrown  jvvay. 

Galyl  has  given  excellent  results  in  the  writer's  experience.  Its  low 
toxicity,  reduced  price  and  equal  efficacy  compared  with  salvarsan  are 
points  to  be  appreciated. 

Intravenous  treatment  always  gives  the  best  results. 

Give  two  injections  eight  days  apart. 

Potassium  iodides  can  be  given  in  large  doses,  I'o — 2*0  grm.  thrice 
daily,  omitted  one  w^eek  in  six.  Continue  the  treatment  for  several 
months  after  the  disease  has  cleared  up. 

Mercury  is  useless. 

16  c.c.  of  serum  of  yaw  patients  already  treated  with  salvarsan  has 
efficient  curative  properties.     Boiling  does  not  reduce  its  power. 

The  ulcers  and  crusts  can  be  washed  wath  perchloride  of  mercury 
to  take  awav  the  smell  and  to  allav  the  itching.  They  may  then  be 
dusted  with  iodoform. 

Protargol  ointment  20  per  cent,  has  been  used  for  ulcerative  lesions. 

THE    DYSENTERIES. 

The  dysenteries  include  a  group  of  diseases  manifesting  abdominal 
pain,  tenesmus,  small,  frequent,  blood-mucous  stools,  ultimate 
emaciation,  and  pyrexia  in  the  bacterial  variety. 

HISTORY. 

3,000  B.C.  Hindu  records  carry  us  back  to  this  time  when  dysentery 
was  divided  into  acute  and  chronic  varieties. 


28  DISEASES  DUE  TO   PROTOZOA 

The  Hindu  surgeon,  Sushrula,  wrote  lliree  to  four  centuries  B.C. 
that  :  — 

"  He  falls  an  easy  victim  to  internal  and  external  diseases  who 
drinks  of,  or  bathes  in,  a  pool  of  water  which  is  full  of  poisonous 
■worms,  or  is  saturated  with  urine,  or  fc'ocal  matter,  or  is  defiled  with 
the  germs  of  vermin  or  decomposed  animal  organisms,  or  is  covered 
over  with  the  growth  of  aquatic  plants,  or  is  strewn  over  with  withered 
and  decomposed  leaves,  or  which  in  anv  ^^•a\•  is  rendered  poisonous  and 
rontaminated,  as  well  as  he  who  drinks  and  kvUlies  in  the  freshlv 
collected  water  of  a  pool  or  reservoir  during  the  rains." 

Hippocrates  seems  to  have  introduced  the  term  "  dysentery  "  and 
to  have  dififerentiated  it  from  diarrhoea. 

Most  ancient  writers  of  the  Near  East  were  acquainted  with  it. 

534  A.D.  there  was  an  epidemic  of  dysentery  in  France. 

820.     It  occurred  as  an  epidemic  in  Hungary. 

1083-1113.      It  was  in  Germany  in  epidemic  form,  and  in 

13 16  it  visited  England  as  an  epidemic. 

Wars,  famine  and  foul  drinking  water  were  the  chief  allies  of  the 
various  epidemics. 

1 2 16.  King  John  died  from  it.  Edward  I  (1307)  and  Sir  Francis 
Drake  (1595)  both  were  attacked  by  it  a  few  days  before  their  deaths. 

141 1.     The  military  camp  at  Bordeaux  lost  14,000  men  by  it. 

1538.  The  first  European  pandemic  took  place,  which  was  followed 
by  at  least  six  others  some  time  later.  Some  of  these  pandemics  lasted 
for  three  years. 

1655.  Cromwell's  failure  to  take  St.  Domingo  was  due  to  dvsenterv. 
There  were  1,700  deaths  during  the  three  weeks  of  the  conflict  among 
the  troops  and  islanders.  The  disease  decimated  the  same  troops  when 
they  took  Jamaica  from  the  Spanish. 

1870.     The  Franco-German  War  lost  2,380  deaths  from  dysenter\-. 

1859.  The  living  amoebcC  were  found  in  the  faeces  at  Prague  bv 
Lambl. 

1873.  Losch  at  St.  Petersburg  found  and  described  for  the  first 
time  the  amoeba  when  he  called  it  "Amoeba  coli,"  an  organism  now 
believed  to  have  been  the  Entamoeba  tetragena  in  that  particular  case. 

1883.  Koch  differentiated  the  two  main  types  of  dysentery,  amoebic 
and  bacillary. 

1893.  Kruse  and  Pasrjuale  differentiated  the  two  types  of  ama?ba>, 
the  harmless  coli  and  the  pathogenic  tetragena. 

1894.  Japan  had  38,094  deaths  from  the  disease  during  the  land 
campaign  with  China.  They  lost  three  from  disease  to  one  from 
Avounds. 

In  the  Russian  War  these  figures  were  reversed. 


THE   DYSENTERIES  29 

In  1897  they  lost  22,300  from  the  same  disease. 

1899-1902.  In  the  South  African  Campaign  1,342  died  from 
dysentery. 

1900.  In  India  the  deaths  from  bowel  complaints  reached  nearly 
half  a  million  (Hirsch). 

In  the  American  Civil  War  the  Federals  lost  37,794  of  their  troops 
from  dysentery  and  diarrhoea. 

CLASSIFICATION. 

(i)  Bacterial,  caused  by  :  — 

B.   dysenteriai   of   Shiga.     (See    section    on    Diseases  due    ta 

Bacteriology.) 
B.  dysenterias  of  Flexner.     (See  section  on   Diseases  due  tO; 

Bacteriology.) 
B.  pvoc\-aneus.   (See  section  on  Diseases  due  to  Bacteriology.) 

and  kindred  organisms. 

(2)  Verminous,  caused  by  :  — 

Schistosoma    japonicum.     (See    section    on    Diseases    due    ta 

Helminths.) 
Schistosoma  haematobium. 
Qisophagostomum  brumpti. 
Faciolopsis  buski. 
Gastrodiscus  hominis. 

(3)  Protozoal,  caused  by  :  — 

Amoeba  (amoebic). 

Balantidium  (ciliar). 

Kala-azar  (Leishmanic).     (See  article  on  Kala-azar.) 

Malaria  (Laveranic).     (See  article  on  Malaria.) 

(4)  Pseudo-dysenteries.     (]\Iost  common  in  temperate  climates.) 

These    manifest    diarrhoea,    blood-mucous    stools,    abdominal. 

pain  and  tenesmus. 
The  causes  are  :  — 

Intestinal  tuberculosis. 
Intestinal  cancer  and  polypi. 
Inflamed  internal  haemorrhoids, 
Gummata  of  rectum, 
Intussusception, 

Errors  of  diet,  e.g.,  small  fish  bones  eaten  by  natives,. 

ptomaines,  e.g.,  ricin, 
excreta  of  locusts  in  water  (Prout). 
Deeks  classifies  the  Dysenteries  of  Ancon  Hospital  thus  :  — 

(i)  Amoebic  dysentery,  caused  by  E.  histolytica  of  Schaudinn.. 
(2)  ,,  ,,  ,,  E.  tetragena  of  \^iereck. 


30 


DISEASES  DUE  TO   PROTOZOA 


(3)  Bacillary  dysenteiy,  caused  by  Shiga's,  Flexner's  and  allied 

bacilli. 


(4)  I^ilharzial 

(5)  Balantidial 

(6)  Malarial 

(7)  Tuberculous 


M 


>> 
»> 


(8)  Nephritic 


Schistosoma   mansoni. 
Balantidium  coli. 
The  malarial  parasite. 
Tubercle  bacilli   of   Koch   in 
the  intestinal  ulcers, 
associated  with  acute  diffuse  nephritis  or 
secondary  to  chronic   nephritis  with 
an  acute  process  superadded. 
(9)  Diphtheric  colitis,  a  very  fatal  form. 

(10)  Dysentery  in  the  course  of  pellagra. 

(11)  ,,  caused  by  the  ingestion  of  decompcjsing  meats  or 

fish. 

(12)  ,,  secondary  to  cardiac  or  hepatic  disease. 

(13)  Clinical  dysentery,   often  climatic,   when   no  microscopic  or 

cultural  findings  are  successful. 


AMCEBIC   DYSENTERY. 
DEFINITION. 

An  acute  or  chronic  specific  disease  of  the  intestine  caused  by 
Entamoeba  tetragena,  sometimes  accompanied  by  E.  coli,  which  is  said 
to  be  non-pathogenic. 

The  disease  is  generally  insidious  in  onset  with  a  tendency  to 
chronicity ;  relapses  are  common;  there  is  liability  to  liver  abscess.  It 
may  concur  with  other  dvsenteries. 

DISTRIBUTION. 

In  Africa,  Asia,  America,  Europe,  China,  India,  Russia,  Germany, 
in  short,  throughout  the  tropical  world  and  frequently  in  the  temperate 
zone. 

THE  PARASITE. 

This  is  the  E,  tetragena,  but  it  is  not  unlike  the  E.  coli  on  superficial 
observation.  The  following  points  will  assist  in  the  description  and 
differentiation. 


Jt.  tetragena  cysts 


Size 

8  to  30  ^             

Shape 

Spherical,   amoiboid  processes 

sometimes  oval 

Colour 

Greenish 

Protoplasm 

Ectoplasm    tough    for    boring 

purposes.     Ecto-  and    endo- 

plasm    easily    distinguished. 

Ectoplasm  refractile 

E.  coli  cysts 

10   to   40  ;U 

Spherical,  when  resting 

Opaque  :  greyish 

Ecto-  and  endoplasm  not  easily 
distinguished.  Ectoplasm  not 
refractile,  homogeneous 


THE    DYSENTERIES— AMCEBIC 


Pseudopodia 

Vacuoles   ... 
Nucleus 


Chromidian  bodies 
■Contents    ... 

Motility     

Multiplication 


Pathogenicity 


It.  tetrageiia  cysts 

Large  and  easily  distinguished. 
Consists     of    ecto-  and    endo- 

plasm 
Many      

Often  absent,  when  present  its 
structure  is  hidden.  Nuclear 
nien)brane  not  well  defined. 
Changes  position  markedly. 
Never  more  than  four  nuclei 
— hence  "  tetragena" 

There  is  little  chromatin 
Erythrocytes,      bacteria,      pus 

cells,  crystals 
Great  progressive  motility 
In  intestine  by  fission  and  bud- 
ding.     Buds  small,  4jU  with 
two  nuclei.     (^*n  hard  faeces 
and    outside   body   resistant 
spores    are    formed    without 
encystment.     These  develop 
when  ingested. 
Pathogenic,      penetrates      the 
tissues  and  often  causes  liver 
abscess 


E.  coll  cysts 

Hard  to  distinguish 
Entirely  ectoplasm 

Never  more  than  one.  May  be 
absent 

Almost  always  present,  with 
well  defined  nuclear  men-.- 
brane  and  other  structures. 
When  organism  moves,  nu- 
cleus retains  its  relative 
position.  May  be  up  to 
eight  nuclei 

There  is  much  chromatin 

Rarely  cells  or  organisms 

Motility  limited 

In  intestine  by  binary  fission 
and  multiple  fission  into  eight 
amoebulac.  These  are  set  free 
when  ingested 


Never  pathogenic  and  never 
seen  penetrating  the  tissues. 
Never  causes  liver  abscess. 
They  are  limited  to  the  large 
intestine  and  caecum. 


LIFE-HISTORY. 

The  E.  tetragena  reproduces  in  tliree  ways  :  — 

(i)  By  binary  fission,  discovered  bv  Schaudinn.  The  nucleus 
divides  by  amitosis  into  two,  and  then  the  cytoplasm  splits 
into  two  ecjual  daughter  cells. 

(2)  By  gemmation. — Found  by  Schaudinn  to  be  more  frequent 

than  binary  fission.  The  nucleus  divides  by  amitosis  into 
two  or  more  daughter  nuclei  with  a  portion  of  the  cytoplasm, 
which  then  separates  off  from  the  mother  cell,  the  daughter 
cells  being  the  smaller. 

(3)  By  spore  formation. — The  chromatin  becomes  diffused,  collects 

around  the  periphery,  the  nucleus  disappearing.     The  ecto- 
plasm forms  into  small  knob-like  processes,  each  containing 
several    chromidia.     These    become    separated    off    and   are 
surrounded  with  a  yellowish-brown  envelope,  forming  spores 
ready    for    infecting   a    new    host    (Schaudinn).     These   are 
surrounded   by   a  cyst   wall    which    is   broken    down    when 
ingested  and  the  eater  infected. 
These   E.    tetragena   are   found    in    the    faeces,    intestinal    contents, 
debris  from  dysenteric  ulcers,  liver  abscesses,  mucosa  and  submucosa 
of   intestinal    wall.     On    the   warm    stage  th^y   show   active   amoeboid 
movement.     The  cyst  resists  drying. 


3-^ 


DISEASES  DUE  TO   PROTO'ZOA 


Wenyon  has  reproduced  the  disease  in  cats,  but  if  it  is  commonly 
present  in  animals  is  not  known. 

It  should  not  be  forgotten  that  the  drv  spores  can  be  carried  by 
flies  and  wind  (Vedder). 

Some  afifirm  that  the  presence  of  intestinal  bacteria,  e.g.,  paracolon 
bacillus,  is  necessary  for  the  growth  of  the  amoebae  (Lesage). 

Flies  are  blamed  as  mechanical  carriers  of  the  parasite  from  faeces 
to  food  (Wen3'on). 

PATHOLOGY. 

Microscopic. — The  spores  enter  the  body  with  drinking  water  and 
food,  producing  young  amoebie  in  the  large  bowel.     These  enter  the 


Entamaba  colt  :  life  cycle,  a — <;,  stages  in  binary  fission  :  A — Z),  schizogony,  with  formation 
of  eight  merozoites  ;  2  —  lo,  cyst  formation  or  sporogony,  with  formation  of  eight  nucleate  cysts. 
(After  Castellani  and  Chalmers.) 


mucosae  by  Lieberkiihn's  follicles,  entering  the  lymphatics,  and  pass- 
ing to  the  submucosa,  they  feed  upon  the  tissue  cells  and  erythrocytes 
of  the  blood.  They  may  destroy  the  tissue  and  enter  the  tributaries 
of  the  portal  vein  or  branches  of  the  mesenteric  artery,  sometimes 
causing  thrombosis.  They  find  their  way  to  the  liver,  causing  hepatitis 
and  liver  abscess  in  15  per  cent,  of  cases. 

Patches  of  the  mucosa  become  oedematous  and  infiltrated  bv  small 


THE   DYSENTERIES— AMCEBIC 


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34 


DISEASES  DUE  TO   PROTOZOA 


cells,  a  small  slough  is  cast  off  and  an  ulcer  formed,  which  then  deepens 
considerably.     Bacteria  aid  the  work  of  ulceration. 

The  ulcers  are  rounded  or  oval,  lying  transversely  with  undermined 
edges,  and  may  penetrate  the  muscular  and  even  the  peritoneal  coat, 
perforating  the  same  and  setting  up  peritonitis  or  abscess.  In  some 
instances  black  scars  are  formed  and  the  ulcer  repaired.  The  blackness 
is  due  to  the  union  of  hydrogen  sulphide  from  the  bowel  with  iron  from 
the  blood. 

Constriction,  stenosis  and  progressive  emaciation  may  ensue.  The 
bowel  may  become  gangrenous. 


A--' 


..Bv 


-A 


Section  through  wall  of  large  intestine  (ul  a  i.jaaj  close  under  an  ulcer  caused  by  Entainceba 
histolytica.  A,  amoebce  that  have  penetrated  partly  in  blood-vessels  Bv,  partly  in  tissue  of 
submucosa  to  the  muscularis.     Magnified.     (After  Harris.) 


Amoebae  may  be  carried  to  the  spleen  and  salivary  glands,  causing 
abscess. 

Macroscopic. — Cardinal  features. 

Body  emaciated,  abdomen  sunken,  rigor  mortis  early,  decom- 
position quickly  sets  in,  the  tissues  are  dry,  the  large  intestine  is 
contracted,  thickened,  and  sometimes  gangrenous. 

Perforation  and  purulent  peritonitis.  INIesocolon  congested  and  often 
adherent.     The  neighbouring  glands  are  enlarged  and  hyper^emic. 

The  colon  is  adherent  externally  to  the  surrounding  structures. 

The  mucosa   is  reddened,    ulcerated,    infiltrated   chiefly   in  cascum, 


THE    DYSENTERIES— AMCEBIC 


35 


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36 


DISEASES  DUE  TO    PROTOZOA 


hepatic  flexure  and  sigmoid.     There  are  also  firm  nodules  surrounded 
by  dilated  vessels,  which  later  become  ulcerated. 

The  remains  of  the  submucosa  is  thickened,  also  the  muscular  coat. 


6 


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The  liver  is  fatty,  perhaps  congested ;  there  may  be  one  or  more 
abscesses.     For  details,  see  article  on  Liver  Abscess. 

SYMPTOMATOLOGY. 

Acute  amoebic  dysentery. 

Onset  is  usually  sudden,  pain  in  the  lower  abdomen  often  severe, 
much  griping  and  straining  at  stool,  stools  up  to  thirty  per  diem  with 


THE    DYSENTERIES— AMCEBIC 


37 


Eniamaba  histolytica  in  tissue.  Section  of  submucosa  of  colon,  fixed  in  corrosive  sublimate 
and  alcohol,  and  stained  with  nigrosin.  Three  entamoeba  may  be  seen  following  each  other  in 
a  tunnel  which  the  leader  is  excavating.  E,  Entamoeba  ;  G,  glandular  tissue  (disintegrating) ; 
Z,  sniall  cell  infiltration.      X  350. 


Entamceba  histolytica  in  mucosa  of  colon.  Invasion  of  the  crypts  of  Lieberkiihn  from  the 
interglandular  tissue,  and  subsequent  destruction  of  epithelium  by  the  organisms.  E,  Entamoeba  ; 
Z,  small-cell  infiltration  ;  B,  blood  corpuscles  and  debris,      x  300.     (After  Dopter.) 


blood    and    mucus,     leucocytes,     amoebae,     bacteria,     Charcot-Leyden 
crystals  and  bits  of  tissue. 

Anorexia,  moist  furred  tongue,  sometimes  nausea  and  vomiting. 


38 


DISEASES  DUE  TO   PROTOZOA 


Dyspepsia,  pain  along  line  of  large  gut. 

Pulse  and   respirations  quickened.      Red   cells   diminished, 
cytes  and  eosinophiles  increased. 


leuco- 


Section  of  intestine  from  a  case  of  amcebic  dysentery,  showing  a  typical  "  ulcer  of  Harris." 

X  45- 


iifj^^^i 


Section  of  small  amoebic  abscess,  in  which  the  pus  pushed  through  the  muscular  tissue,  and 
collected  beneath  the  serous  coat  of  the  peritoneum.     X  85. 

Urine  diminished  with  some  albumin  and  casts  usually. 
Remittent  fever  may  be  present  or  absent. 

Normal  temperature,  absence  of  pain  and  tenderness  after  they  have 

been  manifested  may  indicate  :    Recovery,  haemorrhage,  or  gangrene. 

The  condition  of  the  stools  will  indicate  if  the  condition  is  improving. 


THE    DYSENTERIES— AMCBBIC 


39 


Death  ma}-  result  in  seven  to  ten  days  from  exhaustion,  perforation, 
peritonitis  and  haemorrhage. 
Chronic  amoebic  dysentery. 
This  folloAvs  the  acute,  or  it  may  be  insidious  in  onset  not  preceded 


Experimentally  infected  cat's  colon.  Under  the  higher  magnification,  the  glands  of  Lieberkiihn 
are  seen  to  be  full  of  entamoeba,  which  have  destroyed  most  of  the  epithelium,  and  are  traversing 
the  basement  membrana.      x  350.     (After  Jiirgens.) 


En/aviaba  histolytica.  Organisms  in  dysenteric  mucus.  X  400.  The  granular  piotoplasm 
occupies  almost  the  entire  cell,  and  is  distinguished  from  the  ectoplasm  only  by  a  slight  difference 
in  shading. 

by  an  acute  attack ;  there  is  diarrhoea,  with  occasional  abdominal  pain 
and  passage  of  fc-eculent  material  with  much  mucus  and  perhaps 
streaked  with  blood.  In  between  attacks  there  may  be  constipation. 
Stools,  which  are  often  more  frequent  at  night,  are  from  twelve  to  four- 


40 


DISEASES  DUE  TO  PROTOZOA 


Amoebic  suppuration  of  the  brain.  Section  of  a  minute  abscess.  The  cavity  contains 
numerous  entamcebse  and  pus  corpuscles.  The  nuclei  of  both  are  deeply  stained.  (After 
Legrand  and  Dopter.)      x  300. 


Balantidium  coli. 
a, nucleus;  ^.vacuole; 
c,  peristome;^,  bolus 
of  food.  (After 
Leuckart.) 


n 


Balantidium  coli,  free  and  encysted  ;  a,  anus 
or  cytopyge  ;  ;/,  macronucleus  ;  b,  bolus  of  food, 
(After  Casagrandi  and  Barbagallo.) 


Balantidium  coli.     a.  Natural  condition  ;  b,  reproduction  by  binary  fission  ;  c,  reproduction  by 

sexual  conjugation. 


THE    DYSENTERIES— AMCEBIC  41 

teen  per  diem.  The  condition  may  persist  for  years,  resulting  in 
marl-ced  emaciation. 

Large  offensive  sloughs  may  be  passed  at  any  time. 

The  cysts  are  responsible  for  the  spread  of  infection,  hence  carriers 
are  a  danger  to  a  community.     Certain  carriers  manifest  no  symptoms. 

Before  a  naked-eye  examination  of  the  stools  they  should  always 
be  Avashed.  Errors  in  diet  can  be  more  readily  detected  and  corrected 
by  this  means. 

The  Amoeba  minuta  lives  on  the  surface  of  the  mucous  membrane, 
but  is  capable  of  maintaining  the  infection.  After  an  acute  attack 
caused  by  A.  tetragena  the  A.  minuta  may  lead  to  a  relapse  of  the  acute 
condition,  but  by  itself  alone  it  is  doubtful  if  it  causes  any  symptoms. 

One  must  not  forget  that  the  amoebse  are  not  confined  to  the  bowel. 

Urinary  amocbiasis  is  not  infrequent  in  Indians  and  other  Asiatic 
races. 

Because  of  the  possible  widespread  distribution  of  the  amoebae  in 
the  human  body  some  have  used  the  term  Amoebiasis  in  preference  to 
Amoebic  Dysentery. 

The  stools  should  always  be  washed  under  the  tap  when  one  is 
searching  for  cysts,  and  in  all  dysenteric  cases  it  should  be  done 
systematically  with  every  stool.  The  washing  should  be  continued 
until  all  traces  of  faecal  matter  have  disappeared.  This  method  enables 
the  physician  to  differentiate  the  sloughs  and  mucus.  The  diet  can 
also  be  controlled  and  any  undesirable  ingested  foods  detected. 

It  is  often  necessary  to  concentrate  the  cysts  in  doubtful  cases. 

The  method  is  as  follows  :  — 

(i)  Shake  up  for  half  an  hour  about  one  gram  of  faces  with  300  c.c. 
of  normal  saline  until  the  fa?cal  mass  is  disintegrated  and  an  emulsion 
is  formed. 

(2)  Pour  it  into  a  separating  funnel,  and  shake  for  half  a  minute 
with  one-twentieth  of  its  volume  of  ether  or  methylated  spirits.  The 
facal  matter  absorbs  ether  and  becomes  lighter  than  the  water.  Cysts 
are  not  aft'ected  by  the  ether  and  remain  at  the  bottom  in  the  saline. 

(3)  Draw  off  the  saline  from  the  separating  funnel  and  centrifuge 
it  for  several  minutes.  The  bottom  of  the  tube  should  contain  the  cysts 
in  about  fifteen  times  more  concentration  than  the  ordinary  faeces 
(Cropper  and  Row). 

Colonel  Wenyon  has  shown  that  the  mobile  stage  of  the  pathogenic 
amoeba  is  not  infectious  by  the  mouth.  Indeed,  "the  cystic  phase  is 
the  sole  cause  of  transmission,"  and  these  cysts  are  able,  under  favour- 
able circumstances,  to  live  for  at  least  a  month  outside  the  body. 

COMPLICATIONS. 

Hepatitis,  liver  abscess,  gangrene  of  bowel,  peritonitis,  haemorrhage, 
stenosis  of  sigmoid,  abscesses  in  other  parts. 


42  DISEASES  DUE  TO   PROTOZOA 

DIAGNOSIS. 

From  Bacterial  Dysentery  by  its  chronic  course,  rare  pyrexia, 
absence  of  toxic  symptoms,  complication  of  liver  abscess  and  the 
iinding-  of  the  amcx^bcU  in  the  stools. 

When  examining  the  stools  for  amoebie  a  little  methylene  blue  \vill 
stain  the  pus  and  epithelial  cells,  but  not  the  amoebae,  thus  facilitating 
their  detection  and  examination.  It  is  not  important  in  practice  to 
diagnose  A.  tetragena  from  A.  coli,  if  one  employs  the  rule  that  if  the 
symptoms  of  dysentery  are  present  and  amoebae  are  seen  in  the  stools 
treat  as  for  amoebic  dysentery. 

Wenyon  suggests  that  the  stool  should  be  examined  \vith  a  little 
iodine  tincture,  so  that  the  nuclei  may  be  well  seen  with  an  oil  immer- 
sion and  No.  2  eyepiece,  the  condenser  slightly  lowered  to  reduce  the 
light. 

Amcebic  Bacillary 

Nearly  always  chronic  in  its  course  Nearly  always  acute 

Pyrexia  rare  Pyrexia  common 

Toxic  symptoms  absent  or  late  when  no  Toxic  symptoms  usually  present 

liver  abscess 
Liver  abscess  in  15  per  cent,  of  cases  Never  liver  abscess,  unless  multiple  and 

small 
Small  intestine  frequently  attacked  Nearly    always     confined    to    the    large 

intestine 
Amoebae  found  in  the  stools  Dysentery  bacilli  found  in  the  stools 

From  Sub-tertian  malarial  dysentery  hv  the  absence  of  malarial 
parasites  the  presence  of  fever  and  its  not  yielding  to  quinine  treatment. 

From  Ulcerative  colitis  and  Hcemorrhagic  typhoid  by  high  fever, 
prostration,  pain,  violent  delirium  and  the  absence  of  entamocb^e.  The 
diagnosis  is  often  difficult. 

From  Helminthic  infectio7is  by  finding  the  causative  parasites. 

From  hitestinal  tuberculosis  bv  marked  tenderness  in  the  cascal 
region  rather  than  over  the  sigmoid  flexure  and  the  absence  of  parasites. 

From  Malignant  disease  of  the  sigmoid  and  rectum  by  the  severe 
tenesmus,  increasing  difficulty  to  pass  large-formed  stools,  the  age  of 
the  patient  and  the  absence  of  parasites. 

TREATMENT. 

Absolute  rest  in  bed. 

Relieve  griping  bv  morphia,  hypodermically,  also  by  enemata  or 
suppository.     Give  castor  oil  half  to  one  ounce  (15-30  grm.). 

Emetine  hydrochloride  is  a  specific,  half  a  grain  (0*03  cm.)  dis- 
solved in  normal  saline,  given  twice  daily  until  12  grains  (0*75  cm.) 
have  been  given.  It  can  be  administered  hypodermically :  sterile  tubes 
of  the  drug  can  be  obtained  ready  for  use;  it  may  be  given  orally  as 
"  alcresta  "  ipecacuanha,  ijl  grains  (D"09  cm.)  of  emetine  can  be  given 


THE    DYSENTERIES— AMCEBIC  43 

by  the  mouth  per  diem  in  this  way.  It  can  also  be  given  inlravenously, 
o'lo  grm.  dissolved  in  lo  c.c.  of  saline  daily. 

10-20  per  cent,  of  cases  are  not  cured  by  emetine. 

Emetine  bismuth  iodide  in  gelatine  capsules,  one  grain  (o"o6  cm.) 
thrice  daily  per  os  until  36  grains  have  been  given,  has  now  superseded 
the  emetine  hydrochloride  treatment.  It  has  cured  ''  emetine-resistant  " 
cases. 

There  are  several  good  alternative  treatments,  e.g.,  tincture  of 
opium,  15  minims,  followed  in  fifteen  minutes  by  ipecacuanha,  10-20 
grains  in  cachet  or  pill,  twice  daily.  The  best  Brazilian  ipecacuanha 
should  be  used,  as  it  contains  72  per  cent,  of  emetine. 

In  the  chronic  stages,  use  daily  intestinal  irrigations  of  quinine 
bihydrochloride,  1-5,000  to  1-1,000,  ^-^l  litres  slowl}'  injected  through 
a  well-vaselined  rectal  rubber  tube. 

Tannic  acid  is  good,  5-1,000.     Also  protagol,  1-500. 

These  could  be  preceded  by  a  morphia  suppository  half  an  hour 
before.  Later  a  bismuth  mixture  could  be  given,  followed  by  a  tonic. 
It  is  a  good  practice  to  give  small  doses  of  emetine  later  to  prevent 
relapses. 

There  could,  of  course,  be  a  combined  treatment  of  emetine  and 
ipecacuanha. 

Decks  strongly  advocates  the  bismuth-milk  treatment  as  follows  :  — 

Rest  to  increase  resistance  and  diminish  bowel  movement.  Generous 
milk  diet — it  is  absorbed  before  reaching  the  large  bowel.  Saline  or 
water  irrigation  thrice  daily  to  wash  away  toxic  products.  Bismuth 
subnitrate,  grains  180,  a  heaped  teaspoonful,  mechanically  suspended 
in  a  tumbler  of  water;  effervescent,  three  hourly,  day  and  night  in 
severe  cases,  reduced  as  the  patient  improves.  When  the  stools  are 
few  and  the  tongue  clean  give  it  thrice  daily.  The  bismuth  salt  locks 
up  the  free  and  the  nuclear  sulphur  of  the  bacteria  in  the  intestine.  It 
destroys  certain  organisms  and  influences  others. 

Entamoeba  show  early  degenerative  changes  (James),  become 
vacuolated,  swollen  and  fragmented.  The  characteristic  faecal  odour 
disappears.  The  entamoeba  usually  disappear  after  the  fourth  day,  no 
matter  how  serious  the  condition. 

Too  much  opium  favours  retention  of  toxic  products  that  irritate 
the  normal  mucous  membrane  and  interfere  \\illi  (he  production  of 
enzymes  and  hinder  digestion. 

C^costomy  in  selected  cases  of  emaciation  and  exhaustion  (Herrick) 
should  be  done.  It  prevents  food  residue  from  reaching  the  ulcerated 
colon,  admits  of  better  irrigation  of  the  bowel,  and  makes  possible  a 
more  varied  and  generous  diet ;  but,  on  the  other  hand,  convalescence 
is  lengthened  and  a  restorative  operation  is  necessary  later. 


44  DISEASES  DUE  TO   PROTOZOA 

Sir  Patrick  Manson  recommends  simaruba  officinalis  as  follows  :  — 

Simaruba  bark  ...         ...         ...         ...         ...    Grm.  15 

Pomegranate  fruit  rind  ...         ...         ...         ...        ,,      15 

Gum  Arabic      ,,      15 

Add  water  to  one  litre  and  boil  to  half  its  bulk. 

Give  one  ounce  (30  grm.)  thrice  daily. 

Dapter  suggests  a  creosote  rectal  wash,  i — 100,  twice  daily.  He 
maintains  that  the  creosote  is  absorbed,  and  acts  upon  the  amoebae  in 
the  tissues  and  in  the  localities  where  other  drugs  have  failed  to  reach 
them. 

The  administration  of  sulphates  at  the  same  time  as  other  treatment 
will  assist  in  washing  out  the  bowel,  but  patients  must  not  be  exhausted 
by  their  prolonged  use. 

A  dry  but  varied  diet  is  most  generally  useful. 

Men,  dogs  and  cats  act  as  carriers  without  obvious  symptoms,  and 
should  be  treated  pro  bono  publico. 

Remark. — The  Entamoeba  tetragena  can  cause  a  serious  cystitis  of 
the  urinary  bladder  quite  apart  from  any  dysenteric  affection  (Wright). 

CILIAR   DYSENTERY. 

(i)  Balantidium  coli  (sometimes  B.  minutum)  may  cause  trouble- 
some intestinal  disturbances,  such  as  occasional,  remittent  or  persistent 
diarrhoea,  in  which  the  parasites  can  be  found. 

Blood  and  mucus  are  present  in  all  the  severe  cases. 

Peritonitis  may  occur  with  or  without  perforation. 

Extensive  ulceration  is  found  in  fatal  cases,  most  marked  near  the 
rectum,  and  less  so  in  the  direction  of  the  caecum. 

Sometimes  there  is  vomiting,  with  oedema  of  the  face  and  ex- 
tremities.    It  is  chiefly  confined  to  the  large  intestine. 

The  diagnosis  can  only  be  made  by  the  microscope. 

There  is  no  specific  treatment. 

The  mortality  is  about  30  per  cent. 

It  is  most  common  in  the  Philippines,  Japan  and  Europe. 

THE  PARASITE. 

It  is  an  oval-shaped,  large,  ciliated  infusorian,  30 — 200  fx  x  20 — 70  ju,. 
It  reproduces  by  division,  budding  and  conjugation. 
It  may  lose  its  cilia  and  become  encysted. 
It  is  a  common  parasite  of  the  pig. 
It  is  very  active  in  liquid  human  stools. 

It  has  been   found  post-mortem   in   the   exudate,    follicles,    ulcers, 
muscular  coat,  blood-vessels  and  lymphatics  of  the  intestine. 
The  method  of  infection  is  unknown. 


THE    DYSENTERIES—CILIAR 


45 


Balantidium  coli.     Living  forms  in  the  dejecta  of  Balantidian  dysentery. 


;.»  ».-%:. 


■^. 


v.'..-:*.! 


rezf^zt^ 


Balantidium  coli.  Invasion  of  the  wall  of  the  sigmoid  flexure  in  a  case  of  Balantidian 
dysentery.  A,  Mucus  ;  B,  glandular  infiltration  and  destruction  ;  C,  parasites  in  the  connective 
tissue  of  the  submucosa,  with  infiltration  of  small  cells.      (After  Dopter.) 


46 


DISEASES  DUE  TO   PROTOZOA 


Balantidium  con.     Parasites  in  a  lymph  space  of  the  submucosa.     (AftcrDopler.) 


Balantidiuin  tninnttifii.     P,  Peristome  ;  A'',  nucleus  ;  I\I,  micro-nucleus  ;    V,  vacuole. 

(After  Schaudinn.) 

TREATMENT. 

Castor  oil,  salines,  intestinal  irrigation  \\itli  tannic  acid  or  cjiiinine. 
Emetine  and  ipecacuanha  can  be  tried. 

Methylene  blue  has  been  recommended,  rectal  injections,  and  by 
the  mouth. 


(2)  Laniblia  intestinalis  is  probably  pathogenic,  attacking  prin- 
cipally the  small  intestine.     It  is  common  in  India. 

The  tissues  are  not  invaded,  but  one  may  have  a  chronic  recurrent 
diarrhoea  with  abundant  mucus,  with  bile  or  blood  stains.  There  are 
usually  intervals  of  relief  between  attacks  with  constipation. 

The  parasite,  a  split  pear-shaped,  double  nucleated,  protozoon  with 
a  sucking  disc,  can  be  found  in  the  diarrhoea  excretions. 

The  disease  is  chronic  and  may  last  thirty  years. 

When  searching  for  the  parasite  one  should  note  the  two  flagella 
at  the  (ail  end.  There  are  also  three  other  pairs  from  the  central 
nuclei.  There  are  two  nuclei,  one  on  either  side  of  the  longitudinal 
dividing  line;  its  aspect  is  not  unlike  that  of  a  face.  The  parasite, 
about  12 — 18  yu  long,  soon  dies  on  leaving  the  body,  but  it  is  very 
persistent  in  the  host. 

Lamblia  is  a  common  parasite  in  rats  and  mice,  in  which  it  causes 
an  enteritis.     These  rodents  probably  form  a  reservoir  of  infection  for 


THE    DYSENTERIES— CI  LIAR 


47 


Lainhlia  intestinalis.  A,  ventral  view  ;  B,  side  view  ;  N,  one  of  the  two  nuclei  ;  ax,  axostyles  ; 
fl'^,fi'',Jl^,P,  the  four  pairs  of  flagella  ;  s,  sucker-like  depressed  area  on  the  ventral  surface: 
jir,  bodies  of  unknown  function.     (After  Wenyon.) 

man.     The  cysts  have  been  found  in  the  fajces  of  the  common  house 
fly,  which  probably  acts  as  an  insect  porter  (Bahr). 

TREATMENT. 

Free  purgation  and  intestinal  antiseptics.  Enemata  are  not  much 
use  for  the  small  intestine. 

Methylene  blue  can  be  tried,  i — 2  grains,  with  or  without  liquid 
paraffin,  ;}  ounce,  thrice  daily. 

Beta-naphthol  has  been  tried. 

(3)  Trichomonas  intcstinalis  is  the  common  intestinal  flagellate  in 
man  which  lives  in  the  large  intestine  and  ca?cum.  It  is  a  large  pear- 
shaped  bod}'  with  three  free  flagella  and  one  attached  to  the  undulating 
membrane.  Its  movements  are  very  rapid,  but  a  sixth  objective  will 
reveal  its  characters.     It  will  survive  outside  the  bodv  for  days. 

Some  assert  that  it  is  harmless,  being  found  usually  where  other 
organisms  have  deranged  the  intestine. 
Encysted  forms  have  not  been  proved. 

(4)  Tetramitis  mcsn'ili  has  been  blamed  for  intestinal  irritation, 
followed  by  diarrhoea.  It  somewhat  resembles  the  trichomonas,  but 
the  latter  has  an  undulating  membrane  and  no  large  cytostome  like  the 
former.  It  dies  in  a  few  hours  when  passed  in  the  f^ces,  while  tricho- 
monas persists  for  days.     It  may  not  be  pathogenic. 


48  DISEASES  DUE  TO   PROTOZOA 

(5)  Less  well  known  causative  ciliar  parasites  are  :  — 

Colpoda  ciscullus. 
Nyctotherus  faba, 

„  giganteus. 

Cercomonas,   Bodo,   Prowazekia  are  rare.      Each  of  ihem  possess 
flagella  from  the  blunt  end  of  organism,  but  they  cannot  be  seen  until 
a  few  days  after  the  faeces  have  been  passed. 
They  are  not  pathogenic. 
They  all  probably  have  an  amoeboid  stage. 

(6)  Coccidia,  Genus  Isospora,  have  been  found  in  faeces  of  patients 
from  Gallipoli,  and  are  now  regarded  as  having  some  pathogenic 
significance  in  man.  Little  is  yet  known  of  them,  except  in  animals 
and  birds. 

LIVER    ABSCESS. 

INCIDENCE. 

In  India  the  native  soldiers  are  seventeen  times  less  liable  to  hepatitis 
than  the  European  soldier,  and  twenty-five  times  less  liable  to  liver 
abscess. 

VARIETIES. 

Single  :  These  are  tropical  in  75  per  cent,  of  cases,  and  are  due  to 
amoebae,  ascarides  and  gallstones. 

Multiple  :  Usually  pyasmic,  sometimes  coccidia. 

POSITION  (Cantlie). 

Supra-hepatic  :   The  pus  lies  between  the  layers  of  the  suspensory 

ligament;   is  seldom  associated  with   dysentery; 

the  pus  is  usually  sterile. 
Intra-hepatic  :    Usually  amoebic;  the  pus  is  always  infected. 
Sub-hepatic  :   Rare,  and  when  present  is  not  dysenteric. 

CAUSATION. 

Traumatism,  chiefly  pyogenic  cocci. 

Gallstones,  chiefly  B.  coli  communis. 

Parasites,  amoebae,  ascarides,  hydatids,  coccidia,  distoma  rare. 

Direct  extension,  from  right  empyasma,  peritonitis,  right  peri- 
nephritis. 

Typhoid,  along  the  bile  ducts  from  the  intestine  or  by  pylephlebitis, 
or  directly  from  a  focus  of  suppuration. 

Pyaemic,  along  the  portal  vein  after  dysentery,  gastric  or  duodenal 
ulcers,  appendicitis,  abscess  of  spleen  or  pancreas,  after  treatment  for 
haemorrhoids,  sepsis  of  umbilical  cord,  along  the  hepatic  artery,  after 
septic  injuries  of  the  cranium,  otitis  media,  ulcerative  endocarditis  and 
septic  diseases  of  the  lungs. 


LIVER  ABSCESS 


49 


c4 


c 
•o 

u 


50  DISEASES  DUE  TO   PROTOZOA 

AMCEBIC    ABSCESS. 
HISTORY. 

21  per  cent,  of  dysenteric  autopsies  in  various  tropical  countries  had 
liver  abscess. 

35  per  cent,  of  European  soldiers  in  India  who  died  from  dysentery 
had  liver  abscess. 

84*4  per  cent,  of  the  patients  at  the  Seamen's  Hospital  who  had 
liver  abscess  revealed  at  the  post-mortem  evidence  of  dysentery. 

Liver  abscess  is  more  common  in  Europeans  than  natives  and  in 
males  than  females. 

Waring  savs  that  65  per  cent,  of  liver  abscess  cases  were  alcoholics. 

The  disease  is  more  common  between  the  ages  of  20  and  40,  but 
may  occur  at  any  age. 

In  90  per  cent,  of  cases  the  organism  is  associated  with  or  derived 
from  dysenteric  processes  in  the  colon. 

Liver  abscess  was  operated  upon  in  the  days  of  Hippocrates. 

PATHOLOGY. 

The  abscess,  which  is  usually  single,  is  most  frequently  in  the  right 
lobe  of  the  liver.  It  is  so  frequently  in  the  right  lobe  because  the 
patient  is  in  bed,  and  the  right  lobe  being  heavier  than  the  left  lies 
lower,  and  the  amoebas  coming  along  the  portal  vein  are  assisted  by 
gravity  to  affect  the  lower  or  right  lobe.  No'  matter  how  large  the 
abscess  may  be  it  never  crosses  over  to  the  other  side,  and  in  this  it 
simulates  hydatids  and  malignant  growths. 

There  is  no  anastamosis  or  communication  whatever  between  the 
vessels  (jf  the  two  sides;  injection  has  proved  this.  There  are  really 
two  livers  arising  from  two  distinct  buds  from  the  gut  and  the  gall- 
bladder lies  between  them  (Cantlie). 

An  abscess  may  occupy  half  the  liver,  and  the  patient  recover 
because  the  other  half  takes  on  the  work,  as  in  the  case  when  one 
kidney  is  removed.  There  is  no  doubt  that  the  whole  liver  is  enlarged 
and  congested.     The  right  lower  lobe  of  the  lung  is  congested. 

The  abscess  wall  is  thick,  firm,  ragged,  and  is  made  up  of  three 
layers  :  — 

(i)  The  outer  layer  is  of  hyper^emic  liver  tissue  with  some  con- 
nective tissue.     In  some  cases  a  fibrous  capsule  may  be  formed  from  it. 

(2)  The  middle  layer  is  of  brownish  red  friable  liver  tissue. 

(3)  The  inner  layer  consists  of  grey  necrosed  tissue  containing 
amoebae  and  pus  cells,  the  latter  less  frequently.  There  is  no  lining 
membrane. 

The  contents  of  the  abscess  consist  of  a  viscid  chocolate-coloured 


AMCEBIC    ABSCESS  51 

pus,  with  red  blood  here  and  yellow  mucus  there,  while  a  little  green 
bile  may  add  to  the  variety  of  colour.  The  pus  is  not  readily  taken  up 
by  the  dressing  and  has  a  peculiar  smell.  The  pus  is  usually  sterile. 
Under  the  microscope  can  be  seen  red  blood  cells,  broken  down 
liver  tissue,  large,  granular,  pigmented,  spherical  cells,  leucocytes, 
debris,  oil  globules,  h^ematoidin  crystals,  amceb^e,  and  very  rarely 
pyogenic  cocci.  Amoebae  are  best  seen  four  days  after  the  operation 
coming  through  the  drainage  tube.  They  persist  until  the  abscess  has 
healed  (Manson).  The  necrosis  is  thought  to  be  due  to  the  toxic  action 
of  the  E.  tetragena. 

SYMPTOMATOLOGY. 

There  is  nearly  always  a  history  of  dysentery,  but  amoebic 
diarrhoea  is  not  uncommon.  Rogers  states  that  30  per  cent,  of  his 
cases  gave  no  history  of  dysentery,  14  per  cent,  of  no  bowel  disturb- 
ance, but  98  per  cent,  of  them  revealed  ulceration  and  scarring  post 
mortem. 

There  is  chill,  headache,  foul  tongue,  loss  of  appetite,  languor  and 
depression.  Weight  and  fulness  in  the  right  hypochondrium,  sharp 
stabbing  pain  often  affecting  the  right  shoulder  and  arm  from  the 
phrenic  nerve  and  the  fourth  cervical  to  the  brachial  plexus. 

Cough,  according  to  the  extent  of  the  irritation  of  the  diaphragm 
and  pleun-e;  there  is  often  dyspnoea  due  to  the  base  of  the  lung  being 
affected. 

Sweats  at  night,  earthy  tint  of  skin,  emaciation. 

Breathing  rapid  and  shallow,  chiefly  on  the  right  side,  and  thoracic. 

Pulse,  80 — 100;  hands  and  feet  cold.     Rigors  sometimes. 

Right  rectus  rigid;  the  left  is  not  so.     Pain  on  palpation. 

The  whole  right  side  bulges,  and  the  intercostal  spaces  are 
obliterated. 

The  liver  dulness  is  higher  than  normal  and  arched  abDve.  It  is 
also  lower  than  normal. 

Pleuritic  friction  may  be  heard. 

The  body  is  often  bent  to  the  right  side  and  the  right  leg  flexed. 

Cutaneous  oedema  of  the  chest  wall  is  common,  but  oedema  of  the 
feet  and  ascites  are  rare. 

Vomiting  may  occur  from  gastric  irritation  due  to  pressure. 

Occasionally  one  sees  varicosity  of  the  epigastric  and  h^emorrhoidal 
veins. 

Jaundice  is  not  constant,  and  is  but  slight. 

There  is  leucocytosis,  the  polymorphs  going  up  to  74 — 87  per  cent. 

Basal  pneumonia  of  the  right  lung  alone  in  a  dysenterv  patient 
should  arouse  suspicions. 


52  DISEASES  DUE  TO   PROTOZOA 

DIAGNOSIS. 

From  Hepatitis  by  :  — 

A  definite  epigastric  swelling  compatible  with  liver  abscess,  X-ray 
examination  and  surgical  exploration. 

The  trouble  is  not  progressive,  but  often  intermittent. 

Chronic  malaria  with  hepatitis  may  be  troublesome,  but  the  spleen 
also  \\ill  be  enlarged  considerably. 

Tropical  liver  or  febrile  congestion  is  due  to  diet,  alcohol,  &c. 

Intermittent  hepatic  fever  due  to  infective  cholangitis  gives  a  history 
of  cholelithiasis. 

Syphilitic  gummata  by  history,  \\'assermann  and  drug  reaction. 

Enteric,  uncomplicated,  shows  a  leucop^enia. 

Undulant  fever,    Kala-azar  and  Tuberculosis  the  same. 

An  excess  of  mononuclear  leucocytes  is  not  common  in  liver 
abscess,  but  there  is  a  constant  excess  of  polymorphs,  75 — 80  per  cent. 

Double  infections  are  common.  Drugs  will  sometimes  help,  as 
Cjuinine  in  malaria  and  emetine  in  dysenteric  abscess. 

The  stools  should  always  be  examined  for  amo?bai. 

TERMINATION. 

The  abscess  may  run  lis  course  in  from  three  weeks  to  three  nionihs. 
It  ma\'  burst  and  refill  or  encyst  and  give  rise  to  no  more  symptoms. 
28  per  cent,  rupture  spontaneously,  and  usually  into  the  lung,  peri- 
toneum or  pleui'cC.  There  ma}'  be  5 — 10  ounces  of  ]3u.s  couglied  up  in 
twenty-four  hours.  Recovery  may  ensue  or  sudden  h^emoptosis  result. 
The  pus  coughed  up  or  vomited  from  the  stomach  may  cease  and 
recover\-  take  place,  or  the  whole  series  of  symptoms  may  be  repeated. 

When  there  is  spontaneous  rupture  the  possible  positions  are  as 
follows  :  — 

Into  the  abdomen  or  intestine;  here  the  pus  causes  the  intestines 
to  become  matted  together,  but  the  pus  is  sterile.  This  condition 
should  never  be  operated  upon;  the  pus  will  be  absorbed.  A^^hen  into 
the  intestine  the  pus  is  passed  per  anum  and  usually  missed.  When  it 
passes  into  the  peritoneum  a  fatal  peritonitis  has  been  caused. 

Into  the  stomach  when  the  pus  is  vomited. 

Into  the  pleura,  rare;  causes  empvema. 

Into  the  lung,  may  bog  its  base,  give  rise  to  signs  of  pleurisy, 
expectoration  of  pus  and  blood;  70  per  cent,  recover  (Groves). 

Into  the  pericardium,  when  it  is  rapidl}'  fatal. 

Into  the  inferior  vena  cava,  rapidly  fatal. 

Into  the  gall-bladder,  when  the  pus  is  passed  ])er  anum  with  possible 
recovery. 

Externally,  by  the  skin,  when  the  prognosis  is  at  its  best. 


AMCEBIC    ABSCESS  53 

The  pus  may  pass  between  the  two  la)'ers  of  the  Hgamentum 
puhnonis  and  here  penetrate  the  bronchus,  but  it  never  passes  from 
the  lung  tissue  into  the  bronchus  (CantHe).  The  pus  is  then  like 
anchovy  sauce. 

The  mortality  of  Liver  Abscess  is  always  high,  50 — 80  per  cent. 

In  Algiers,  80  per  cent.     In  the  Indian  Army,  57*7  per  cent. 

TREATMENT. 

Liver  abscess  can  often  be  prevented  if,  when  there  are  signs  and 
symptoms  of  hepatitis,  treatment  is  adopted  as  for  amoebic  dysentery. 

When  the  abscess  has  once  formed  operation  is  the  only  thing. 

The  starvation  diet  before  operation  should  not  be  observed  in  these 
cases.  From  two  to  three  hours  before  give  a  very  nutritious  and  easily 
digestible  meal,  well  sweetened.  It  prevents  some  of  the  evil  effects 
of  the  chloroform  poisoning  dependent  upon  the  state  of  ihe  liver 
(Cantlie). 

Always  give  a  general  anaesthetic. 

Insert  the  needle  to  diagnose  correctly.     If  pus,  then  operate. 

When  the  pus  is  in  the  left  half  of  the  liver,  which  is  verv  rare,  do 
not  explore  with  a  needle,  nor  use  a  trocar  and  cannula,  but  cut  down 
and  evacuate  the  pus  in  the  ordinary  Avay. 

In  mapping  out  the  liver  before  operating  remember  :  — 

That  the  left  margin  of  the  liver  does  not  coincide  with  the  right 
costal  margin.  In  a  tall  man  it  is  normally  above,  and  in  a  short, 
stout  man  below  the  costal  margin,  as  the  ribs  pass  out\\ards  more 
transversely. 

To  get  the  lower  border  for  that  particular  patient  place  the  patient's 
hand  (right)  with  the  upper  border  at  the  articulation  of  the  sternum 
with  the  ensiform  cartilage  and  draw  a  line  along  its  lower  border;  this 
is  the  normal  lower  border  line  of  his  liver.  Each  inch  below  this  line 
means  one  pound  of  liver  extra,  and  this  is  serious  (Cantlie). 

Examine  for  an  egg-shaped  swelling  along  the  upper  border 
between  the  right  nipple  and  the  sternum. 

Remember  that  the  pleura  comes  to  within  three  fingers  breadth  of 
the  lower  costal  margin  and  the  lung  to  five  fingers  breadth. 

When  needling,  it  does  not  matter  if  the  pleura  is  penetrated. 

Even  if  the  base  of  the  lung  is  pierced  it  is  not  of  importance,  as 
this  is  congested,  doing  no  work,  and  the  puncture  will  relieve  the 
tension. 

Bleeding  from  the  hepatic  veins  is  good;  it  relieves  congestion  and 
affords  comfort  even  if  no  abscess  is  found. 

The  portal  vein  has  never  been  entered. 

The  vena  cava  is  4I  inches  away  from  any  part  of  the  surface  of  a 


54  DISEASES  DUE  TO   PROTOZOA 

normal  chest,  so  that  a  needle  of  3I  inches  in  length  can  do  no  harm 
in  any  case. 

Do  not  insert  the  needle  where  the  liver  overlaps  the  stomach. 

Do  not  forget  that  one  lobe  may  be  enlarged  by  overwork  becau.se 
the  other  is  atrophied. 

It  is  possible  to  miss  the  abscess  after  six  punctures. 

Always  incise  the  skin  first,  then  use  the  needle,  or  a  piece  of  skin 
may  block  the  needle.  Never  aim  at  the  vena  cava  each  time  as  some 
areas  are  thus  missed. 

To  evacuate  the  pus  a  special  trocar  and  cannula  are  required, 
that  is,  when  the  abscess  is  in  the  right  half  of  the  liver;  the  cannula 
should  be  3J  inches  long;  the  vena  cava  is  4J  inches  distant  from  the 
surface.  Push  the  cannula  off  the  trocar  when  the  end  is  inserted  in 
the  liver,  and  the  liver  cells  are  by  this  means  pushed  aside  and  not  cut. 

Do  not  wash  the  abscess  cavity  out  with  carbolic;  it  coagulates  the 
blood  and  causes  it  to  resemble  pus. 

Remove  the  ribs  below  the  pleura,  if  necessary,  and  put  in  a  tube. 
This  tube  can  be  of  greater  diameter  than  the  cannula  and  inserted 
by  stretching  it  upon  a  special  rod,  which  is  then  inserted  down  the 
cannula,  the  cannula  withdrawn,  the  rod  liberated  from  the  rubber 
tube  by  an  appliance  and  withdrawn,  leaving  the  tube  in  situ,  exer- 
cising pressure  upon  the  surrounding  liver  cells  and  preventing  pus 
from  leaking  into  the  pleural  cavity.  Haemorrhage  is  also  thus  pre- 
vented. Do  not  evacuate  all  the  pus  before  the  tube  is  inserted  or  the 
abscess  cavity  will  collapse,  and  there  will  not  be  a  cavity  in  which  to 
insert  the  rubber  tube. 

The  after-treatment  is  all-important. 

Drain  the  abscess  by  syphoning.  Attach  to  the  rubber  tube  a  glass 
tube,  and  to  this  a  rubber  tube  passing  to  a  bucket  by  the  bedside. 

If  the  syphon  action  is  excessive  blood  may  come ;  then  raise  the 
bucket  on  to  a  stool,  then  a  chair,  then  on  to  the  bed,  and  so  reduce 
the  suction  until  the  desired  effect  has  been  obtained. 

Give  emetine  at  the  same  time  as  for  amoebic  dysentery. 

Retain  the  tube  in  position  for  two  to^  ten  weeks,  shortened  from 
time  to  time  as  required,  keep  it  in  until  the  bile  comes  or  the  pus  has 
all  been  evacuated.  Then  remove  the  syphon  tube,  and  shorten  the 
rubber  tube  as  the  liver  pushes  it  out. 

When  bed  sores  arise  turn  the  patient  on  to  his  side. 

If  the  fever  still  remains  there  are  more  abscesses  or  the  drainage 
has  been  insufficient. 

If  the  abscess  is  aseptic,  irrigate  dailv  with  c}uinine  i  — 1,000,  but 
remember  that  such  fluids  with  flocculi  of  pus  may  enter  the  open 
mouths  of  the  hepatic  veins  and  may  prove  rapidly  fatal. 

Patients  treated  for  Liver  Abscess  should  never  return  to  the  tropics. 


TROPICAL   LIVER  55 

Operation  has  reduced  the  mortality  to  32  per  cent. 

Canthe  had  115  recoveries  with  27  deaths. 

Some  aspirate  the  abscess  and  inject  c^uinine  bihydrochloride, 
0-50  grm.  to  the  litre  (Rogers  and  Wilson). 

Quinine  kills  the  amoebae  on  the  abscess  wall,  and  the  pus  becomes 
less  copious  and  almost  serous  as  long  as  it  is  sterile. 

Change  the  dressing  at  least  twice  daily;  the  pus  tends  to  run  by 
the  side  rather  than  into  the  dressing. 

Failure  of  this  treatment  is  due  to  :  — 

(i)  A  secondary  abscess  which  may  burst  into  the  first  cavity. 

(2)  Septic  infection.     Culture  the  pus  organisms. 

(3)  Insufficient  emetine. 

(4)  Intercurrent  disease,  e.g.,  enteric  fever,  &c. 

TROPICAL    LIVER. 

This  is  a  distinctive  disease  affecting  Europeans  residing  in  the 
tropics.  It  is  more  prevalent  generally  during  the  early  years  of 
residence. 

The  foul  tongue,  painful  liver,  earthy  skin,  and  irritable  temper  of 
such  affections  are  well  known. 

The  liver  functions  are  adversely  affected  by  heat,  food,  alcohol, 
malaria,  abuse  of  exercise,  congestion  and  inflammation. 

TREATMENT  (Rogers). 

Absolute  rest  in  bed. 

External  applications,  such  as  hot  fomentations  on  oleate  of  iodine. 

Internal  medication,  e.g.,  salicylate  of  sodium,  ammon.  chloride, 
sodium  sulphate,  pot.  iodide,  ipecacuanha.  Also  calomel,  blue  pill, 
soda  and  phenalgin,  followed  by  a  saline  purge. 

Ipecacuanha  is  most  useful  if  there  is  hepatitis.  Give  it  in  large 
doses  on  an  empty  stomach,  20 — 40  grains  at  night,  preceded  by 
chloral,  20  grains. 

Ipecacuanha  in  keratine  capsules  does  not  act  until  it  has  reached 
the  intestine,  and  hence  is  to  be  recommended. 

THE    LEISHMANIASES. 

These  will  be  considered  under  the  following  heads  :  — 
(i)  Kala-azar. 

(2)  Infantile  kala-azar. 

(3)  Dermal  Leishmaniasis  (Oriental  sore). 

(4)  Naso-oral  and  Oro-phalangeal  Leishmaniasis. 

(5)  Canine  Leishmaniasis. 

(6)  Pseudo-kala-azar  (Tropical  febrile  splenomegaly). 


56  DISEASES  DUE   TO    PROTOZOA 

Kala-azar. 
DEFINITION. 

A  chronic,  specific,  infective,  febrile  disease,  caused  by  Leishmania 
donovani ;  characterized  by  irregular  fever,  enlargement  of  the  spleen 
and  liver,  emaciation  and  anaemia,  frequent  hyperpigmentation  of  the 
skin,  and  accompanied  by  a  heavy  mortality. 

HISTORY. 

1869.  It  was  noticed  by  British  officers  in  India,  decimating  and, 
in  some  instances,  depopulating  numerous  districts  of  the  Garo  Hills. 
The  Garos  called  it  "  kala-azar,"  or  the  black  fever, 

1875.     It  became  epidemic  with  a  very  heavy  mortality. 

1882.     The  first  account  of  it  was  published  by  Clarke. 

1889.     It  spread  to  Assam  along  the  lines  of  communication. 

1900.  Sir  William  Leishman  found  the  parasite  in  the  spleen  of 
a  soldier  at  Xetley,  but  he  did  not  publish  it  until  1903,  in  which  vear 
Donovan  found  the  parasite  by  splenic  puncture  during  life. 

1907.  Patton  found  the  parasite  in  the  leucocytes  of  the  peripheral 
blood,  also  that  it  became  flagellated  in  the  alimentary  canal  of  bugs. 

DISTRIBUTION. 

It  is  endemic,  and  may  become  epidemic  in  East  India,  Assam, 
Madras  and  Calcutta.  It  is  present  in  Arabia,  Ceylon,  Burma,  Indo- 
China,  China,  the  Yangtse  valley,  Sudan,  Egypt,  Tunis,  Algeria, 
Sicily  and  Portugal. 

The  Indian  epidemic  began  in  the  Lower  Bengal  at  the  foot  of  the 
Garo  Hills,  slowly  advancing  up  the  valley  of  the  Bramaputra,  travel- 
ling 100  miles  in  seven  years. 

■It  followed  the  lines  of  intercourse,  attacking  first  the  larger 
stations.  Isolated  villages  seemed  to  escape.  As  it  spread  into  new 
villages  ahead  it  died  out  in  those  first  attacked. 

It  seemed  to  cling  to  a  place  for  about  six  years,  and  then  died  out 
without  apparent  cause.  A  house  would  appear  to  retain  the  infection 
for  months. 

The  disease  terrorized  the  natives,  those  afiflicted  were  expelled  from 
their  villages,  made  semi-drunken,  and  taken  into  the  bush  to  be 
destroyed. 

There  have  been  sporadic  cases  in  other  parts  difficult  to  account 
for,  although  they  seemed  to  be  typical  cases  of  Kala-azar. 

AETIOLOGY. 

The  disease  is  spread  by  Leishmania  donovani. 

The  carrier  blamed  by  Donovan  is  a  Conorhinus. 

The  predisposing  causes  are  explained  by  the  habits  of  bugs  thus  : — • 


LEISHMA  NIA  SIS—KA  LA  -A  ZA  R 


57 


An  epidemic  will  travel  slowly  along  lines  of  human  commimication, 

It  runs  in  families,  the  children  suffering  most. 

The  poorer  sections  of  the  community  are  affected  most. 

The  dwelling  becomes  infected  and  will  infect  those  close  to  it. 

Neither  sex  nor  season  has  anv  influence. 


WM. 


kx 


A 


4ff 


^  '■  is 


Leishmania  donovani.  i,  Free  forms,  each  with  nucleus  and  rod-shaped  blepharo- 
plast  (after  Christopheis)  ;  2,  endothelial  cell  and  leucocytes  containing  parasites  (after 
Christophers)  ;  j,  capillary  in  the  liver  showing  endothelial  cells  containing  parasites  (after 
Christophers)  ;  4,  two  parasites  escaping  from  a  leucocyte  in  the  alimentary  canal  of  the  bug 
(after  Patton)  ;  5,  further  development  in  bug  (after  Patten) ;  6,  young  flaggellate  forms  in  bug 
(after  Patton)  ;  7-//,  culture  forms  (after  Leishman) ;  7,  8,  g,  show  development  of  flagellum. 


THE  PARASITE. 

The  l^eishman-Donovan  "  body  "  is  a  small  ovoid  or  roundish 
organism,  2 — 4  /i  in  diameter;  when  stained  it  shows  two  lilac- 
coloured  chromatin  masses  of  unequal  size  enclosed  in  a  c_ytoplasm 
of  a  bluish  tint. 

The   larger   mass   is  the   nucleus,   oval   and   centrally   placed   in   the 


58  DISEASES  DUE    TO    PROTOZOA 

resting  stage,  elongated,  and  situated  peripherally  in  the  pre-division 
stage. 

The  smaller  mass  is  the  muco-nucleus  or  blepharoplast,  a  short 
rod,  perpendicular  or  at  a  tangent  to  the  nucleus. 

The  parasite  multiplies  by  simple  fission,  the  nuclear  masses  always 
elongating  and  dividing  before  the  protoplasm. 

The  parasites  are  almost  always  intracellular  in  man. 

Their  growth  and  multiplication  within  the  cell  causes  the  cell  to 
enlarge  and  disrupt ;  these  parasites  set  free  enter  other  endothelial 
cells  or  are  engulfed  by  leucocytes  in  which  they  may  be  seen  in  the 
peripheral  circulation.  Clusters  of  them  may  be  seen,  50 — 200,  in 
a  structureless  matrix  debris  of  the  host  cells. 

In  cultures  the  parasite  enlarges  rapidly,  becomes  elongated,  and 
acquires  a  flagellum  at  its  rounded  end  acquired  from  the  blepharoplast, 
the  whole  measuring  12 — 20  /x  in  length. 

Attempts  to  transmit  the  parasite  to  vertebrates  have  failed. 

The  parasite  can  be  cultured  from  the  blood,  even  during  apyrexial 
periods,  on  N.N.N,  media.  Ten  or  twelve  tubes  of  this  media  should 
be  inoculated,  otherwise  parasites,  if  scanty,  may  not  be  secured. 
Eight  out  of  ten  tubes  may  be  negative.  It  is  the  flagellate  form  of 
the  parasite  that  develops  in  the  cultures  (Cornwall  and  Menon). 

Run  a  few  drops  of  finger  blood  into  15 — 20  c.c.  of  citrated  saline 
solution,  centrifuge  it,  inoculate  N.N.N,  media  with  the  deposit  of 
corpuscles. 

Donovan  believes  that  a  biting  insect  carries  it  to  man,  while 
Manson  suggests  that  insects  might  deposit  it  upon  (he  wounded  and 
abraded  surfaces  of  man. 

Once  in  the  body  it  enters  an  endothelial  cell  of  a  capillary  blood- 
vessel or  lymphatic,  and  therein  grows  and  multiplies  until  up  to  220 
may  be  seen  in  one  cell  (Leishman). 

The  liver,  spleen,  bone  marrow  and  hmphatic  glands  may  be  thus 
affected,  less  so  the  pancreas,  kidneys,  suprarenals,  testicles  and  lungs. 

The  enclosing  cell  ruptures,  the  liberated  parasites  are  taken  up  by 
leucocytes,  polymorphonuclears,  mononuclears,  and  rarely  eosino- 
philes,  as  a  result  of  which  process  the  parasites  appear  in  the  peripheral 
circulation,  especially  if  a  diarrhoea  due  to  intestinal  ulcers  increases 
the  polvmorphonuclears. 

The  further  development  takes  place  in   ihe  bug,   but   ihe  complete 
life-cycle  has  still  to  be  ascertained. 

INCUBATION. 

Not  yet  ascertained. 

One  case  was  under  ten  days. 

It  is  generalh'  considered  lo  be  from  (liree  ^\•epK's  lo  sp\eral  months. 


LEISHMA  NIA  SIS—KA  LA  -A  ZA  R 


59 


SYMPTOMS. 

Onset  is  often  by  rigor,  which  may  recur  daily. 

Initial  fever  is  irregular,  high,  intermittent  (jr  continuous,  showing 
a  double  remission  daily  on  a  four-hourly  chart. 

Vomiting  is  not  infrequent. 

Less  frequently  there  are  gastro-intestinal  disturbances,  or  in  some 
instances  the  onset  is  insidious. 

Secondary  low  fever  is  chronic  in  its  course,  continues  from  two  to 
six  weeks,  then  gradually  declines.  The  spleen  and  liver  enlarge,  may 
be  painful  and  tender.  Then  there  is  an  apyrexial  period,  or  a  very 
mild  fever.  Profuse  sweats  are  common.  Rigors  are  now  rare. 
Apyrexia  and  pyrexia  mav  now  alternate.     The  anaemia  increases. 

Cachexia  is  now  manifest.  There  are  :  asthenia,  wasting  of  muscle 
with  protrusion  of  abdomen.     The  ribs  show,  the  extremities  are  thin, 


TIME 

M 

E 

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M 

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M 

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M 

E 

M 

E 

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M 

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104 

103 

1  02 

1  01 

1  OO 

9  9 

96 

97 

M 

X 

/ 

^ 

% 

t 

A 

A 

\i 

/ 

V 

i 

rf 

fy 

A 

rt 

/ 

\    t 

A 

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r\ 

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,* 

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/•v 

7 

V 

v 

Kala-azar.     Undulating  type. 

cheeks  sunken,  nose  sharp  and  ankles  puffy.  There  may  be  oedema 
of  the  legs  and  ascites. 

The  skin  becomes  an  earthy  grey  colour. 

The  hair  becomes  dull,  dry,  brittle,  and  may  fall  out. 

Epistaxis  and  bleeding  from  the  gums  are  not  uncommon. 

The  spleen  may  nearly  reach  the  pelvis,  but  the  liver  is  not  so  much 
enlarged. 

Diarrhoea  and  dysenteric  attacks  are  common. 

Haemorrhages  may  occur  from  anywhere — nose,  gums,  stomach, 
bowels,  or  under  the  skin. 

There  may  be  a  papular  eruption  about  the  thighs.  Ulcers  may 
form. 


TERMINATION. 

The  disease  goes  on  for  months  or  years,  average  twelve  to  eighteen 
months.  4  per  cent,  improve  slowly,  96  per  cent,  die  of  asthenia  or 
some  intercurrent  disease  (Rogers). 


6o  DISEASES  DUE    TO    PROTOZOA 

Dysentery  carries  ofif  about  90  per  cent,  of  them,  then  comes  phthisis 
and  pneumonia. 

Usually  the  tongue  is  normal  and  the  digestion  good. 

THE  BLOOD. 

The  parasites  may  be  found  in  the  peripheral  circulation. 

There  is  marked  anaemia,  4 — 2,500,000  reds  per  cm.  (Rogers). 

Mb.  is  reduced  in  proportion. 

The  colour  index  is  normal. 

There  is  marked  leucopaenia,  2,000  or  less. 

Polymorphonuclears  and  eosinophiles  are  reduced. 

Mononuclears  and  lymphocytes  are  increased. 

The  reduced  pohs  probably  predispose  to  bacterial  invasion. 

Coagulability  is  decreased;  exploratory^  punctures  may  set  up  a  fatal 
haemorrhage. 

The  whites  to  reds  varv  from  i  to  2,000,  i  to  4,000  reds  instead  of 
I   to  625. 

DIAGNOSIS. 

An  irregular  chronic  fever  with  a  very  enlarged  spleen  and  a  relative 
mononuclear  leucocytosis  is  probably  Kala-azar,  but  one  must  find  the 
Leishman-Donovan  body  to  be  certain. 

Centrifuge  the  blood  for  the  leucocytes. 

To  puncture  the  spleen  is  dangerous,  but  is  practised  at  times. 

Some  artificially  excite  bullcC  for  the  leucocytes. 

A  blood  examination  will  exclude  a  leukaemia. 

The  double  dailv  remission  of  fever  is  important. 

Banti's  disease  is  sometimes  troublesome;  the  microscope  only  will 
exclude  it. 

PROGNOSIS. 

This  is  always  bad.  Moderate  estimates  state  that  70  per  cent,  die 
who  have  had  treatment,  and  96  per  cent,  without  it. 

The  increase  of  the  polys  is  a  good  sign. 

Better  results  may  be  obtained  by  tartar  emetic,  intravenously  and 
in  strong  doses.     The  writer  suggests  Injectio  antimonii  oxide. 

MORBID  ANATOMY. 

The  body  is  emaciated.     There  is  marked  muscular  atrophy. 

There  is  some  oedema  present. 

The  spleen  is  much  enlarged,  it  is  firm,  deep  red  in  colour,  the 
capsule  thickened  and  congested  throughout.  Many  parasites  may  be 
seen.     The  spleen  sometimes  weighs  80  ounces. 

The  liver  is  somewhat  enlarged,  the  intra-lobular  arteries  are 
dilated,  they  contain  macrophag"es  full  of  parasites,  the  liver  cells  are 


LEISHMANIASIS— INFANTILE   KALA-AZAR  6i 

atrophied  and  degenerated.  Sometimes  the  cirrhosis  is  severe  and  no 
parasites  are  seen. 

There  may  be  ulcerations  of  the  sl<in  and  the  intestine. 

There  may  be  hemorrhages  in  various  parts. 

The  bone  marrow  cells  show  numerous  parasites,  the  yellow  marrow 
has  become  red,  soft  and  diffluent. 

Intestinal  ulceration  is  very  common,  parasites  may  be  found  in 
the  walls  of  the  ulcers  and  the  proximal  lymphatic  glands. 

Parasites  are  sometimes  found  in  the  kidney  blood-vessels,  but 
never  in  the  secretory  tubules. 

TREATMENT. 

Antimony  tartrate  or  sodium  antimonyl  tartrate  has  been  found 
most  useful,  given  intravenously.  Rogers  claims  to  have  had  good 
results. 

The  following  prescription  is  useful  :-  — 

J^,    Tartar  emetic     ...         ...         ...       2  gnn. 

Liq.  fowleri         ...         ...         ...       6  c.c. 

Aq.  dist.  a.  ...         ...         ...  300  c.c. 

Of  this  2  c.c.  diluted  with  distilled  water,  intravenous,  twice  weekly. 

Antimony  oxide  is  well  worth  a  trial, 

Others  have  used  atoxyl,  3  grains,  every  other  day  intramuscularly 
(Manson  and  Low). 

Others  have  used  quinine,  60 — 90  grains  daily,  until  the  temperature 
falls,  then  20  grains  daily. 

Salvarsan  is  useless. 

Other  treatment  is  symptomatic  :  — 

Good  food  and  hygiene. 

Calcium  chloride  or  lactate  for  haemorrhages. 

All  other  diseases  in  the  patient  should  be  cleared  up. 

Isolate  the  patient,  disinfect  infected  dwellings,  destroy  all  bugs. 

Infantile  Kala-azar. 
SYNONYMS. 

Leishmania  anaemia.  Splenomegaly. 

Febrile  splenic  anaemia.  Ponos. 

DEFINITION. 

A  subacute  or  chronic  specific  disease  resembling  Kala-azar,  caused 
by  L.  infantum  and  occurring  in  childhood. 

DISTRIBUTION. 

Southern  Europe,  North  Africa,  Mediterranean  shores  and  islands. 


62  DISEASES  DUE    TO    PROTOZOA 

^ETIOLOGY. 

The  causative  organism  is  Leishmania  infantum. 

The  carriers  blamed  are  Pulex  irritans  and  P.  serraticeps. 

The  parasite  is  indistinguishable  from  L.  donovani  morphologically, 
but  the  latter  is  not  inoculable  with  success  into  dogs. 

The  parasite  can  be  found  in  the  peripheral  circulation,  bone 
marrow,  spleen  and  liver  in  both  children  and  dogs. 

The  organism  can  be  cultured  and  subcultured  indefinitely. 

The  disease  can  be  reproduced  in  monkeys  and  dogs,  but  the  latter 
are  spontaneously  infected  and  may  form  the  reservoir  of  the  virus  and 
its  ectoparasites,  e.g.,  fleas  (Basile).     Wenyon  doubts  this. 

The  disease  manifests  itself  in  children  usually  between  the  ages  of 
two  and  three  in  the  springtime  and  early  summer. 

Several  members  of  the  family  may  be  attacked. 

The  pathological  findings  are  as  in  Kala-azar. 

SYMPTOMATOLOGY. 

There  is  an  insidious  onset  which  may  coincide  with  an  attack  of 
diarrhoea  and  vomiting. 

These  are  :  irregular  fever,  pallor,  epistaxis,  apathy,  with  some 
enlargement  of  the  spleen. 

Hcemorrhages  from  the  nose,  gums  and  under  the  skin. 

A  diarrhoeic  or  dysenteric  attack  may  be  marked,  alternating  with 
constipation.     The  appetite  is  usually  preserved. 

Wasting,  auccmia  progressive,   1,500,000 — 3,000,000  reds. 

Hb.  is  below  50  per  cent.  Leucocytes  from  1,500 — 3,000.  Mono- 
nuclears form  70  per  cent,  to  80  per  cent. 

Ulcerative  stomatitis  is  not  uncommon.  Noma  on  the  face  or 
genitalia. 

The  spleen  now  enlarges  enormously,  bulging  out  the  abdomen. 

The  pulse-rate  is  rapid,  120 — 160.     Ha&mic  murmurs  are  rare. 

The  opsonic  index  is  low,  especially  for  B.  coli  communis. 

Transient  a^demas  of  any  part  may  occur. 

The  liver  is  generally  enlarged. 

Death  is  from  exhaustion,  rarely  under  six  months. 

Second  attacks  are  rare,  hence  the  Jews  of  Baghdad  at  one  time 
inoculated  their  children. 

COMPLICATIONS. 

Bronchitis,  broncho-pneumonia,  pleurisy,  fatal  dyspnoea  from 
oedema  of  the  glottis. 

Noma  is  common  in  Italy  and  Greece. 
Otitis  media  is  rare. 


LEISHMANIASIS— DERMAL  63 

TREATMENT. 

This  is  very  unsatisfactory. 

Treat  as  for  Kala-azar. 

Splenectomy  is  not  advised  as  the  disease  is  a  general  disorder. 

Cochran,  hoAvever,  claims  good  results  from  operation. 

Infected  dogs  should  be  destroyed. 

Common  cleanliness  will  diminish  the  prevalence  of  fleas. 

Spontaneous  cure  does  take  place  at  times. 

Some  claim  good  results  from  salvarsan. 

Antimony  should  be  tried  as  for  Kala-azar. 

Dermal  Leishaianiasis  (Oriental  Sore). 

DEFINITION. 

A  specific  circumscribed  ulceration  of  the  skin  caused  by  L.  tropica. 

DISTRIBUTION. 

It  is  endemic  in  many  tropical  and  sub-tropical  countries. 

In  the  Sudan  they  have  the  non-ulcerating  type. 

In  South  America  it  is  known  as  "  Forest  yaws." 

It  occurs  in  Morocco,  Tunis,  Tripoli,  Algeria,  Sahara,  Egypt, 
Congo,  West,  East  and  South  Africa,  Syria,  Asia  Minor,  Mesopotamia, 
Arabia,  Persia,  Caucasus,  Turkestan,  Valley  of  the  Indus,  N.W. 
Provinces,  Rajputana  States,  Crimea,  Cyprus,  Crete,  Greece,  Italy, 
Brazil  and  Guiana.  It  is  a  misnomer  to  call  the  disease  "  Oriental 
sore  "  with  this  distribution. 

AETIOLOGY. 

It  is  caused  by  L.  tropica. 

It  is  conveyed  by  direct  contact  between  man  and  man  through 
abraded  surfaces  or  small  wounds.  Insects  may  play  a  part  in  its 
transmission. 

There  is  no  general  infection  in  dogs  occurring  in  the  same  parts 
as  is  the  case  with  Infantile  Kala-azar,  except  perhaps  in  Persia 
(Gachet). 

Laveran  claims  that  house  flies  can  carry  the  parasites  mechanically 
and  could  thus  infect  wounds  and  ulcers. 

Gachet  blames  the  dog  fly,  e.g.,  Hippohosca  canina. 

HISTOPATHOLOGY. 

There  is  atrophy  and  disappearance  of  the  epidermis  of  the  affected 
parts.  There  is  a  cellular  infiltration  of  the  corium  and  papillae  by 
lymphoid  cells,  plasma  cells,  and  large  round  cells.  These  latter, 
which  are  probably  proliferated  endothelial  cells,  are  packed  with 
Wright's  bodies. 


64 


DISEASES  DUE    TO    PROTOZOA 


Tlie  squamous  epithelium  is  surrounded  by  desquamated  epithelium. 
Crusts  are  formed.  The  lymphatic  and  blood  vessels  in  the  deeper 
layers  are  surrounded  by  lymphoid  cells.  There  are  vertical  epithelial 
columns  extending  deeply  down  with  a  few  cell  nests  and  isolated 
masses  of  cell  infiltration. 

It  is  essentially  an  infective  granuloma. 

Hair,  sweat  glands,  sebaceous  glands  and  follicles  are  invaded  and 
destroyed  by  granular  tissue. 


A  case  of  Leishmaniasis  from  South  America.      (Photograph  by  R.   McKay.) 
(From  \ht /ou7-nal  of  the  London  School  of  Tropical  Medicine.) 

Polymorphonuclear  cells  do  not  predominate  in  the  ulcers  as  in 
pyogenic  ulcerations,   but  the  mononuclears  do. 

SYMPTOMATOLOGY. 

The  incubation  period  is  from  a  few  davs  to  a  few  months. 

During  this  period  there  is  usually  some  irregular  fever. 

Then  several  small  spots  appear,  not  unlike  mosquito  bites.  These 
become  red,  markedly  indurated,  increase  in  size,  and  the  surface 
becomes  covered  with  scales. 


LEISHMANIASIS— DERMAL  65 

After  three  to  four  months  ulceration  begins  with  a  yellowisli 
secretion  which  dries  hard.  Some  forms  do  not  ulcerate,  e.g.,  the 
Soudanese.  The  ulcers  sj^read  under  the  scab,  the  surrounding  tissue 
becomes  oedematous,  the  ulcer,  when  the  scab  is  removed,  reveals 
fungating"  granulations.  The  proximal  lymphatic  glands  do  not 
usually  enlarge. 

The  peripheral  blood  shows  distinct  mononucleosis. 

The  time  of  coagulation  is  increased. 

There  may  be  leucocytosis  during  the  fevers,  and  leucopasnia 
between  them. 

Healing  begins  from  the  sixth  to  twelfth  month  by  granulation 
commencing  in  the  centre.  A  pinkish  disfiguring  scar  remains  which 
may  readily  break  down  again.     The  sore  may  be  multiple  or  simple. 

The  ulcer  may  spread  to  the  mouth  or  nose  and  may  attack  the 
mucous  membrane. 

The  sores  are  auto-inoculable  by  scratching. 

Uncovered  parts  are  generally  attacked;  the  face,  hands,  feet,  &c., 
are  most  afifected.     Repeated  attacf^s  often  occur. 

The  non-ulcerating  type  has  been  called  male,  and  the  ulcerating 
the  female  type.  In  some  cases  one  patient  may  show  both  types  of 
the  condition. 

The  ulcers  may  contain  pyogenic  organisms. 

There  are  no  constitutional  symptoms.  The  parasites  are  not 
found  in  the  blood  (Wenyon). 

DIAGNOSIS. 

In  the  endemic  areas  the  diagnosis  is  not  difficult. 

The  following  points  should  be  noted  :  — 

(i)  Does  the  patient  come  from  an  infected  area? 

(2)  Are  the  nodules  and  ulcers  on  uncovered  parts? 

(3)  Is  the  course  of  its  development  tvpical  ? 

(4)  Have  the  proximal  glands  enlarged  ?  If  so,  it  is  probably  not 
Leishmaniasis. 

(5)  Have  the  L.  tropica  been  found  in  the  scrapings? 
vSyphilis  and  Yaws  are  excluded  by  treatment. 

A  chancroid  on  the  face  is  difficult.  One  should  decide  by  the 
scrapings. 

PROGNOSIS. 

It  is  good  as  regards  life. 

Phagedcena  may  cause  death  by  secondary  septicaemia  and 
pyaemia. 

Serious  disfigurement  may  ensue  about  the  face. 

5 


66  DISEASES  DUE    TO    PROTOZOA 

The  ulcers  are  troublesome  and  unsightly  rather  than  painful  and 
dangerous. 

TREATMENT. 

This  is  very  unsatisfactory. 

Try  nitrate  of  mercury  ointment. 

Remove  scabs  by  boric  acid  fomentations. 

Disinfect  with  mercurial  solutions. 

Apply  antiseptic  ointments. 

All  wounds  should  be  disinfected  at  once  with  tincture  of  iodine. 

Guard  against  blood-sucking  insects. 

Increased  sanitation  reduces  the  incidence  considerably. 

Dogs  and  camels  may  be  reservoirs  of  the  disease. 

Tartar  emetic  should  be  tried  intravenously  and  its  ointment  applied 
to  the  ulcers. 

The  Nile  boil,  Bucharest  boil,  Sec,  have  nothing  to  do  with  this 
disease.     They  are  pyogenic  in  origin. 

Differentiation  between  Kala-azar  and  Oriental  Sore. 
(After  Balfour  and  Archibald.) 

For  brevity  K.  A.  will  equal  Kala-azar  and  O.  S.  Oriental  Sore. 

Family  distribution. 

K.  A.     An  extraordinary  tendency  to  attack  a  number  of  persons 
in  the  same  family  or  household,  this  family  incidence 
clearly  pointing  to  house  infection. 
O.  S.      Rarely,  if  ever,  more  than  one  person  attacked. 
Age  incidence. 

K.  A.     Children  most  commonly  attacked. 
O.  S.      Adults  the  rule. 
Race  incidence. 

K.  A.     Immigrants  rarely  attacked  before  eight  years'  residence 

in  the  East.    The  majority  of  patients  seen  are  natives. 

O.  S.      Immigrants  attacked   within   a   few  months   to   a   year's 

residence  in  the  East.     The  majority  of  joatients  seen 

are  natives. 

Seasonal  incidence. 

K.  A.  No  seasonal  incidence  known,  though  it  is  probable  that 
the  majority  of  cases  are  infected  in  the  cold  season. 

O.  S.  Affection  first  appears  usually  from  September  to  April, 
and  may  last  for  sixteen  months  or  more. 


LEISHMANIASIS— DIFFERENTIATION  67 

Fevers  typical  of  the  disease, 

K.  A.     Double  remittent  type  of  fever  in  certain  cases.     Double 
continued  type.     Low  continued  type.     Frequency  of 
different  types  of  fever  in  various  stages  of  the  disease. 
O.  S.      No  fevers. 

Recovery  after  septic  complication. 

K.  A.     Such  as  cancrum  oris. 

O.  S.      Septic  complications  no  effect,  as  the  parasite  thrives  best 
in  cultures  with  masses  of  cocci  and  bacteria. 
Effect  of  quinine. 

K.  A.     Large  doses  in  early  cases  have  cured. 
O.  S.      No  result. 

General  symptoms  in — ■ 
K.  A.     Early  cases  give  history  of  rigors  daily,  headache,   sick- 
ness,    ^s  per  cent,  of  cases  in  hospital  show  diarrhoea, 
and  7  per  cent,  dysentery. 
O.  S.      None  of  these  symptoms  present. 
Spleen  and  Liver. 

K.  A.     Enormous  enlargement  of  both  viscera. 
Coagulability  of  blood  decreased. 

O.  S.      No  enlargement  of  viscera,  and  coagulability  increased. 
Distribution  of  parasite. 

K.  A.  Polynuclear  leucocytes  infected.  Spleen,  liver,  bone 
marrow  heavily  infected.  Intestinal  ulcers  and 
cutaneous   ulcers  contain   the  parasite. 

O.  S.  Superficial  polynuclears  rarely,  if  ever,  contain  the 
parasites,  whereas  they  swarm  in  the  large  mono- 
nuclear cells  seen  in  a  smear. 

Cultivation  and  development. 

K.  A.  At  27°  C,  in  blood  containing  10  per  cent,  citrate, 
parasites  live  for  several  days  and  multiply,  but  there 
is  no  material  alteration  in  their  form,  and  no  increase 
in  size. 

At  22°  C,  and  not  above  2^°  C,  flagellated  forms 
appear. 

Exposure  to  a  temperature  of  about  25°  C.  causes 
rapid  death  and  degeneration  of  the  developing  forms. 

Sterility  of  the  culture  tubes  is  of  crucial  importance. 

Contamination  with  micrococci  and  bacteria  causes 
rapid  death  and  degeneration  of  the  parasites;  staphy- 
lococci the  most  deadly  contamination  for  the  parasite. 


68  DISEASES  DUE    TO    PROTOZOA 

O.   S.      At  28°  C,  in  infecled,  unhealed,  undiluled  serum  w  illi  no 
citrate,  flagella  forms  appear  in  live  days. 
At  28°  C\  flagella  forms  liave  been  obtained. 

Contamination  with  micrococci  and  certain  bacteria 
highly  favourable,  as  the  parasite  develops  sym- 
bioticall}-  with  masses  of  these  organisms. 

Staphylococci  the  most  favourable  contamination. 
Further,  the  most  perfect  monadina  forms  are  seen 
attached  to  large  masses  of  staphylococci. 

Xaso-oral   and    Oro-phalangeal   Leishmaniasis. 

There  is  no  real  difference  between  this  and  the  ordinary  Dermal 
Leishmaniasis,  except  that  the  mucous  membranes  of  the  nose,  mouth 
and  pharynx  are  primarily  attacked  by  L.  tropica.  Xaso-oral 
Leishmaniasis  is  also  known  as  Espundia.  The  condition  is  often 
more  chronic  than  the  dermal  condition,  but  it  is  seldom  produced  as 
a  result  of  direct  extension  from  the  skin. 

It  seems  to  be  common  in  I^eru,  Brazil  and  Colombia. 

The  larvnx,  trachea  and  ivsophagus  may  be  aft'ected  by  the  exten- 
sion of  the  granulomatous  ulcerations. 

In  such  cases  death  may  be  due  to  exhaustion  and  am^'loid  disease. 

There  may  be  destruction  of  the  nasal  cartilage  inducing  a  marked 
deformity  of  the  nose;  the  skin  may  be  trdematotis,  with  patches  of 
hard  oedema  below  the  eyes. 

The  breath  may  be  offensive. 

Deglutition  may  be  difficult. 

The  disease  may  last  from  twenty  to  thirty  years,  the  final  appear- 
ance not  being  unlike  that  of  a  cachectic  carcinomatous  patient. 

The  condition  is  much  more  chronic  than  the  dermal  type,  and 
usuallv  commences  in  the  mucous  membranes  primarily,  the  skin 
perhaps   remaining  free  throughout. 

The  microscope  onlv  will  differentiate  it  from  Tuberculosis  and 
Blastomycosis. 

An  attempt  must  be  made  to  destroy  the  initial  lesion,  otherwise  the 
treatment  is  purely  symptomatic. 

Canine  Leishmaniasis. 

This  is  mentioned  only  because  it  is  affirmed  by  some  that  Leish- 
maniasis in  dogs  forms  the  reservoir  of  infective  parasites  in  humans, 
especially  for  Infantile  Kala-azar. 

Pulex  serraticeps,  which  occasionally  feeds  on  man,  can  serve  as 
a  carrier  of  the  disease  because  parasites  develop  in  the  fleas. 

Dogs  have  not  been  infected  by  Indian  Kala-azar. 


MALARIA  69 

In  doQfs  there  is  an  acute  and  a  chronic  form  of  Kala-azar. 

Acute  occurs  in  young  dogs  with  fever,  loss  of  appetite,  wasting, 
tremors,  motor  disturbance  in  the  hind-quarters  and  diarrhoea  (rare). 

The  animal  dies  comatose  in  three  to  hve  months. 

Chronic  with  insidious  onset,  progressive  aucemia,  weakness, 
wasting,  tremors,  &c. ;  spleen  much  enlarged  ;  the  disease  may  resemble 
rabies. 

Pseudo-Kala-azar   (Tropical   febrile  splenomegaly). 

DEFINITION. 

This  is  mentioned  here  because  of  its  clinical  similarity  to  Kala-azar. 

It  is  a  chronic,  irregular,  febrile  disorder  of  unknown  causation, 
characterized  by  splenic  hypertrophy,  gastro-intestinal  disturbance  and 
emaciation. 

DISTRIBUTION. 

South  America,  India,  Ceylon,  China,  Egypt,  Philippines,  North 
Africa  and  Italy. 

It  can  onlv  be  differentiated  from  Kala-azar  by  absence  of  the 
parasites  during  life  and  after  death  by  repeated  examination. 

Spleen  puncture  is  unsuccessful. 

The  febrile  attack  differentiates  it  from  Banti's  disease,  and  splenic 
removal  does  not  effect  a  cure. 

The  prognosis  is  bad. 

Arsenic  and  tartar  emetic  should  be  given. 

IMALARIA  ("Mai  aria,"  Italian  for  "bad  air"). 

DEFINITION. 

Malaria  is  the  term  employed  to  indicate  :  — 

A  group  of  acute  or  chronic  specific  fevers  or  to  morbid  conditions 
arising  directly  therefrom. 

Caused  by  the  vSporozoal  organisms  Plasmodium  malaria,  Plas- 
modium vivax  and  Laverania  malari^e. 

Carried  by  the  Anophelin^e,  in  which  the  parasites  undergo  part  of 
their  life-history. 

Characterized  by  fever,  usually  periodic,  anaemia,  enlargement  of 
spleen,  and  the  deposition  of  a  peculiar  pigment  in  the  viscera  and 
elsewhere. 

Quinine  is  a  specific  treatment  for  most  of  these  conditions. 

HISTORY. 

In  550  B.C.  Hippocrates  recognized  and  differentiated  periodic  fevers 
into  quotidian,  tertian,  sub-tertian  and  quartan. 

Galen,  Celsus  and  other  Romans  also  described  these  fevers 
accurately. 


70  DISEASES  DUE    TO    PROTOZOA 

1640  was  the  first  advance  in  our  knowledge  of  them,  when  the 
introduction  of  cinchona  enabled  a  differentiation  of  malarial  from 
other  febrile  diseases.  This  drug  was  probably  first  used  by  the 
Indians  of  Peru,  and  later  rediscovered  by  R.C.  priests.  The 
Countess  d'El  Cinchon,  the  wife  of  the  viceroy  of  Peru,  sent  some  of 
it  to  Europe,  hence  its  name. 

1 71 7.     The  Italians  used  drainage  as  a  protective  measure. 

1847.  Meckel  described  the  peculiar  pigmentation  found  post 
mortem  in  the  spleen  and  blood  of  one  who  had  died  from  malaria. 

1854.  Planer  demonstrated  the  pigment  in  living  finger  blood 
from  a  malarial  patient.  It  was  not  then  known  that  these  pigments 
were  the  parasites. 

1880.  Laveran  established  definitely  the  parasitic  nature  of  the 
infection.  Golgi  demonstrated  the  definite  correlation  between  the 
development  of  the  parasite  and  the  periodicity  of  the  fever  paroxysms. 

1881.  Mosquito  nets  were  first  used  in  India. 

1885.  Golgi  and  others  distinguished  and  differentiated  species  of 
parasites  and  an  asexual  life-cycle. 

1894.  Sir  Patrick  Manson  suggested  that  the  malarial  parasite 
must  have  an  extra-corporeal  life  and  probably  in  a  blood-sucking 
insect,  e.g.,  the  mosquito. 

1897.     McAllum  saw  the  conjugation  of  living  sexual  forms. 

Ross  demonstrated  malarial  parasites  in  the  stomach  wall  of  the 
mosquito. 

1900.  The  microscope  was  not  much  used  in  the  tropics  prior  to 
this  date. 

It  is  interesting  to  note  that  in  1763,  12,000  Frenchmen  disembarked 
at  Kourou,  French  Guinea.  They  lost  10,000  of  their  number  by  death 
from  disease,  chiefly  malaria,  within  twelve  months. 

AETIOLOGY. 

This  will  be  dealt  with  under  the  heads  of  Predisposing  and 
Exciting  causes. 

Predisposing  causes. 

(i)  Residence  in  an  area  infected  with  malarial  carriers  (humans 
with  gametocytes)  and  mosquitoes  capable  of  transmitting 
the  disease. 

(2)  Residence  in  an  infected  area  Avitli  meteorological  conditions 
of  air,  moisture  and  temperature  particularly  suitable  for 
the  development  of  the  parasite,  their  carriers  and  larvcTS. 
Warm,  marshy  places  in  the  wet  seasons  are  ideal.  There 
must  be  an  average  temperature  of  60°  F.  at  least. 


MALARIA  71 

(3)  Occupation  in  deltas  of  rivers,  low-lying  marshy  districts,  or 

working  in   such  places   as   rice   fields,    recently   deforested 
lands,  &c. 

(4)  Age.     Infants  are  more  readily  attacked  than  adults. 

(5)  Racial.     Native  races  suffer  less  than  immigrant  races  in  an 

infected  country  because  of  the  partial  immunity  of 
indigenous  peoples. 

(6)  Diminished  bodily   resistance  and   the   factors  that   cause   it, 

e.g.,  chills,  starvation,  over-feeding,  the  onset  of  other 
diseases,  chronic  ailments,  &c. 

(7)  Altitude.     Mosquitoes  do  not  thrive  at  high  altitudes  in  the 

tropics  due  to  the  cool  air  and  winds  present  there.    ]^Ialarial 
■    "'  convalescents  should  be  sent  to  the  hills,  but  at  slow  stages. 

(8)  Decomposing  vegetable   matter.     This   is   not   indispensable, 

but  it  is  a  stimulating  factor  for  fly  breeding  when  present. 

(9)  Subsoil    moisture.     Where    the    subsoil    moisture    frequently 

rises  high,  there  facilities  are  afforded  for  fly  breeding, 
given  other  favourable  conditions. 

(10)  Rainfall.     Heavy  rains  wash  out  the  drains,  pools,  and  with 

them  the  contained  larvae.  Less  heavy  rains  fill  them  only. 
Where  water  lies  for  several  weeks  in  the  tropics  mosquito 
breeding  is  stimulated.  Where  there  is  no  water,  as  in  the 
Sahara  desert,  there  is  no  malaria,  the  oasis  excepted. 

(11)  vStrong  winds.     Mosquitoes  fly  a  few  feet  from   the  ground. 

When  wind  or  currents  of  air  prevail,  as  from  fans  and 
punkahs,  mosquitoes  seek  shelter. 

(12)  Trees.     A  belt  of  trees  between  breeding  places  and  dwellings 

is  said  to  be  j^rotective. 

(13)  Time  of  day.     Mosquitoes  bite  most   frequently   just  before 

sunrise  and  just  after  sunset  and  at  night.  In  shady  or  dull 
places  they  will  bite  at  any  time.  There  are  stragglers  at 
all  hours. 

(14)  Disturbance  of  soil.     Tliis  predisposes  in  so  far  as  there  are 

usually  excavations  in  which  puddles  of  water  accumulate 
for  mosquito  breeding. 

In  construction  of  roads,  railwavs,  houses,  forts,  barracks, 
&c.,    carelessness   in    this   respect   may   cost    the   enterprise 
hundreds  of  lives,  as  happened  at  Hongkong. 
Exciting  causes. 

The    exciting   causes   are   P.    malarici?,    P.    vivax,    and    L.    malariae 
because  (Manson)  :  — 

(i)  Their  occurrence   in   the  blood   is  sooner  or   later  associated 
with  the  malarial  clinical  phenomena. 


y2  DISEASES   DUE    TO    PROTOZOA 

(2)  Malarial    fever    is    invariably    associated    with    one    of    these 

parasites  at  some  time  of  its  course  or  another. 

(3)  The  phases  of  a  malarial  fever  bear  a  definite  relation  to  the 

phases  of  the  life-cycle  of  the  particular  parasite  present  in 
the  blood. 

(4)  The     characteristic    pigmentation     of     the     viscera     is     fully 

accounted  for  by  the  pigment-forming  property  of  the 
parasite. 
(5)  Injections  of  malaria-infected  blood  will,  after  an  incubation 
of  twelve  days,  be  followed  by  an  attack  of  malarial  fever, 
and  similar  parasites  can  be  recovered  from  the  blood  as 
those  injected. 

(6)  The    administration    of    quinine    will    clear    up    the    clinical 

symptoms,  and  cause  the  disappearance  of  the  symptoms  in 
the  majority  of  cases. 

(7)  If  certain   species   of   mosquito   which    have   fed   on   infected 

blood  be  dissected  at  intervals,  the  evolution  of  the  parasite 
can  be  followed  out. 

(8)  Mosquitoes  thus  fed,   if  kept  for  a  Aveek,   will,   on  biting  an 

uninfected  man,  produce,  after  incubation,  a  typical  malarial 
attack.  Infected  mosquitoes  from  Rome  sent  to  London 
were  allowed  to  bite  the  son  of  Sir  Patrick  Manson.  A 
tvpical  malarial  attack  followed. 

(9)  If  the  non-immune  is  effectively  protected  against  the  mos- 

quito bite  he  will  not  contract  malarial  fever,  though  living 

in  a  malarial  country. 
Three  factors  are  necessary  for  an  attack  of  malarial  fever  :  — 
(i)  The  malarial  parasite. 

(2)  The  necessary  mosquito. 

(3)  The  non-immune  man. 

If  onlv  two  of  these  factors  are  present  malaria  cannot  exist. 

THE  PARASITE. 

Three  parasites  have  been  mentioned,  but  some  believe  there  are 
others  which  cause  a  quotidian  form  of  the  fever,  but  sucli  have  not 
been  conclusively  demonstrated. 

None  of  these  parasites  have  ever  been  found  free  in  air,  water,  soil 
or  decaying  vegetation. 

The  three  parasites  enter  the  human  body  as  sporozoites,  passing 
from  the  salivary  glands  and  the  hypopharyngeal  canal  of  tjie  mosquito 
into  human  blood  at  the  time  of  the  bite. 

One  mosquito,  when  biting  an  infected  person,  may  take  up  from 
6,000 — 7,000  crescents  per  cmm.  of  blood,  but  they  may  all  perish  by 
phagocytosis  in  the  intestine  of  the  fly. 


MALARIA  73 

Wlien  once  injected  into  human  blood  the  parasite  again  has  the 
risk  of  being  killed,  or  it  may  lie  dormant  in  the  spleen  to  develop 
when  the  resistance  of  the  victim  is  reduced,  or  it  may  multiply  and 
cause  an  attack  almost  at  once. 

Some  da^■s  must  pass  between  the  bite  of  an  infected  moscjuito  and 
the  subseciuenl  attack  of  fever,  because  the  parasites  must  multiply 
enormously  and  generate  sufficient  toxin  to  produce  the  fever.  It  has 
been  estimated  that  350  millions  of  parasites  are  required  in  the  body 
to  produce  a  rise  in  temperature  of  one  degree  F.,  hence  one  may  find 
parasites  in  the  blood  when  an  attack  is  not  anticipated  by  the  patient. 
If  but  few  parasites  are  injected  by  the  mosquito  the  incubation  period 
is  lengthened;  if  many  parasites,  then  it  is  shortened.  The  average 
time  between  the  bite  and  the  fever  is  nine  to  twelve  da\'S. 

During  tliis  period  there  are  premonitory  symptoms,  such  as 
lassitude,  body  pains,  &c.,  so  that  quinine  taken  at  this  time  may  abort 
the  attack. 

The  parasites  may  increase  at  a  very  rapid  rate,  as  shown  by  Ross, 
thus  :  Suppose  that  1,000  protospores  of  P.  vivax  have  entered  the  red 
cells,  only  ten  out  of  the  fifteen  to  twenty  spores  produce,  then  they 
will  increase  as  follows  :  — 

Days         ...     2  ...     4  ...     6  ...     10     fever        ...     12 

Parasites...     10,000     ...     100,000     ...     1,000,000     ...     100,000,000     ...     1,000,000,000 

The  rise  of  temperature  is  caused  by  the  liberating  of  toxins  when 
the  red  cell  is  ruptured  by  the  sporozoites.  The  sexual  forms  take 
no  part  in  producing  the  fever  in  the  patient  in  whom  they  have  been 
found. 

The  pigmentation  of  the  cells  and  organs  is  due  to  the  hjemozoin 
liberated  from  the  parasite  as  the  cell  ruptures. 

The  liberated  young  spores  attack  and  enter  new  red  cells  until  the 
majority  of  the  red  cells  may  be  infected  and  a  critical  condition  arise 
for  the  patient.  In  some  cases,  e.g.,  C][uartan,  the  attacks  may  subside 
owing  probably  to  a  partial  immunity. 

The  merozoites  can  pass  through  the  placenta,  infect  the  foetus  and 
cause  congenital  malaria,  from  which  some  racial  immunity  may  be 
established. 

The  P.  malaricB  lives  in  the  circulatory  blood  chiefly,  and  sporulates 
there  every  seventy-two  hours.  It  gives  rise  to  general  symptoms, 
M'hich  are  known  by  the  term  quartan  malarial  fever. 

The  P.  vivax  lives  in  the  circulatory  blood,  but  sporulates  every 
forty-eight  hours  chiefly  in  the  spleen,  causing  general  symptoms 
known  as  tertian  malarial  fever. 

L.  inalaricB  causes  a  stickiness  of  the  red  cells  so  as  to  cause  them 
to  adhere  somewhat  to  the  capillarv  walls  of  the  organs  in  which  they 


74  DISEASES   DUE    TO    PROTOZOA 

sporulale  every  tliirty-six  lo  forty-eiglu  liours.  The}'  give  rise  to 
severe  local  symptoms  as  well  as  general  ones,  the  local  svmptoms 
differing  as  to  the  part  attacked,  hence  trouble  may  arise  owing  to  a 
mechanical  blocking  of  the  capillaries  of  the  brain,  &c.,  or  to  the  local 
intense  action  of  the  toxin,  or  to  both  of  these  causes  in  one  individual. 
There  result,  therefore,  the  pernicious  manifestations  of  malaria,  e.g., 
in  the  brain,  causing  coma  or  paralvsis;  in  the  ]:)ancreas,  causing 
ha?morrhagic  pancreatitis,  &c. 

These  symptoms  are  known  under  the  term  subtcrtian  malaria. 

Each  type  of  parasite  may  cause  irregular  symptoms  at  first,  but 
each  settles  to  grow,  sporulate  and  to  rupture  their  host  cells  at  the 
same  time,  due  probably  to  the  fact  that  the  toxin  liberated  may  kill 
off  the  immature  forms. 

It  is  to  be  remembered  that  double  and  triple  broods  are  known  of 
the  same  parasite  in  the  same  individual. 

The  parasites  also  have  a  ha.miolytic  action,  destro\'ing  the  red  cells, 
hence  throwing  more  work  upon  the  alreadv  overtaxed  liver.  This 
leads  to  excessive  bile  formation  A\ith  diarrluva  and  bile  in  the  urine. 
If  this  detritus  is  excessive,  the  liver,  not  being  able  to  convert  the 
haemoglobin  into  bile,  some  of  it  will  pass  through  causing  haemo- 
globinuria. 

An  antitoxin  is  formed  which  seems  to  quicklv  neutralize  this 
haemolytic  toxin,  and  may  lead  possiblv  to  a  cure  of  the  disease. 

Starvation  diminishes  the  power  of  the  bodv  cells  to  manufacture 
sufficient  of  this  antitoxin,  hence  relapses  ma\'  occur. 

MORPHOLOGY  AND  HISTOLOGY. 

Each  parasite  has  an  intracorporeal  or  human  cycle,  also  an  extra- 
corporeal or  mosquito  cycle.  Some  affirm  that  there  is  a  latent  phase 
also. 

INTRACORPOREAL  OR   HUMAN  CYCLE. 

This  human  life  span  is  forty-eight  or  seventy-two  hours  according 
to  the  type  of  parasite.  A  few  hours  before  a  febrile  paroxysm  the 
parasites  may  be  seen  in  the  red  cell  as  a  pale,  ill-defined  disc  occupy- 
ing part  or  the  whole  of  the  red  cell  in  the  benign  tertian  form,  dis- 
tending the  cell  in  many  cases. 

Scattered  irregularly  about  this  pale  body  are  many  black  or 
reddish-black  dots  excreted  by  the  parasite.  These  are  called  haemozoin 
{melanin). 

These  parasites  concentrate  into  several  central  blocks,  around 
which  the  parasite,  becoming  segmented,  arranges  its  segments  or 
spherules.     The   cell    ruptures,    the   spherule   escapes    into   the    liquor 


Life-cycle  of  the  tertian  parasite  {Plasmodiuin  vivax.)  Figs,  i  to  17,  X  1,200;  figs.  18  to  27,  X  600.  (After 
Liihe,  based  on  figures  by  i-chaudinn  and  Grassi.)  i,  sporozoite :  2,  entrance  of  the  sporozoite  intoa  red-blood 
corpuscle  ;  3,  4,  growth  of  the  parasite,  now  sometimes  called  a  trophozoite;  5,  6,  nuclear  division  in  schizont ; 
7,  free  merozoites  ;  8,  the  nierozoites  which  have  developed  making  their  way  into  blood  corpuscles,  (arrow  pointing 
to  the  Ielt)and  increase  by  schizogony  (3— 7) ;  after  some  duration  of  disease  the  se.\iial  individuals  appear  ;  ga— 12a, 
macrogametocytes  ;  gft — 12/^  micvogametocytes,  both  still  in  the  blood-vessels  of  man.  If  macrogametocytes  (12a) 
do  not  get  into  the  intestine  of  Anopheles  they  may  perhaps  increase  parthenogenetically  according  to  Schaudinn 
(i2rt  ;  13c— 17c).  The  merozoites  which  ha^e  arisen  (17c)  become  schizonts  3—7.  _  The  phases  shown  underneath  the 
dotted  line  (13—17)  proceed  in  the  stomach  of  Anopheles.  i^l>  and  I4<5,  formation  of  microgametes ;  i3rt  and  14a, 
maturation  of  the  macrogametes  ;  15/',  microgamete  ;  16,  fertilization  ;  17,  ookinete;  18,  ookinete  in  the  walls  of  the 
stomach;  19,  penetration  of  the  epithelium  of  ihe  stomach;  20—25,  stages  of  sporogony  on  the  outer  suiface  of  the 
intestinal  wall  ;  26,  migration  of  the  sporozoites  to  the  salivary  gland  ;  27,  salivary  gland  with  sporozoites. 


76  DISEASES  DUE    TO    PROTOZOA 

sanguinis,  the  pigment  being  liberated  at  the  same  time  is  then  taken 
up  bv  phagocytes,  Avhich  may  also  destroy  many  spherules.  The 
spherules  which  have  escaped  the  phagocytes  attack  and  enter  new  red 
cells.  The  young  parasite  now  shows  active  amoeboid  movements, 
shoots  out  long,  retracting,  slender  pseudopodia,  growing  as  it  feeds 
upon  the  haemoglobin,  converting  the  latter  into  parasites,  protoplasm 
and  iKemozoin  particles.  The  movements  gradually  cease  and 
spherules  are  formed,  completing  the  cycle.  The  ha?mozoin  particles 
show  a  Brownian  movement,  otherwise  the  particles  are  now  passive. 

The  voung  parasite  contains  nucleus  and  nucleolus,  which  break 
down  and  become  diffused  in  the  protoplasm,  only  to  reappear  as  small 
scattered  nucleoli  around  which  the  parasite  segments  itself.  As  long 
as  the  nucleus  remains  entire  the  h^emozoin  is  situated  at  the  periphery  ; 
when  the  nucleus  becomes  segmented  the  h^emozoin  becomes  central. 

These  facts  are  not  sufficient  to  describe  the  latency  of  the  parasites 
in  the  body,  and  their  recurrence  causing  later  a  typical  attack  of  the 
fever.  It  is  known  that  good  powers  of  resistance  and  quinine  favour 
latencv,  but  that  reduced  resistance  discourages  it. 

EXTRACORPOREAL  OR  MOSQUITO  CYCLE. 

When  fresh  mounted  malarial  blood  is  watched  under  a  microscope, 
for  ten  to  thirty  minutes  certain  parasites  may  be  seen  to  throw  out 
long  slender  processes,  one  to  six,  giving  the  cell  a  cuttle-fish-like 
appearance.  These  flagella,  or  more  correctly  microgametes,  act  like 
spermatozoa,  since  this  is  the  male  form.  These  vigorous  filaments, 
four  to  six  times  as  long  as  the  diameter  of  the  body  of  the  cell,  break 
away,  swim  free  in  the  liquor  sanguinis,  and  are  lost  to  sight. 

These  flagellated  cells  are  derived  from  crescent  bodies  and  other 
large  parasites  just  prior  to  the  concentration  of  h^emazoin  and  seg- 
mentation. Such  bodies  are  only  formed  seven  to  ten  days  after  the 
onset  of  acute  malarial  symptoms.  These  cells  may  not  be  numerous, 
but  thev  persist  after  all  other  forms  of  the  parasite  have  disappeared, 
and  mav  be  seen  from  one  to  six  weeks  after  all  clinical  symptoms  have 
cleared  up.  After  this  time  they  may  gradually  disappear.  These 
crescents  are  not  affected  by  quinine. 

Thompson  has  shown  that  gametes  as  individuals  do  not  persist, 
but  that  there  is  an  asexual  cycle  which  produces  the  gametes  from 
time  to  time.  The  individual  gametes  do  not  live  very  long  in  the 
peripheral  circulation,  probably  about  ten  da}s ;  if  they  persist  after 
that  time  it  is  because  the  asexual  cycle  has  not  been  killed.  Hence, 
when  gametes  can  be  found  relapse  is  always  possible  and  probable. 
Others  agree  with  Thompson  in  this. 

The  severity  of  the  infection  does  not  account  for  the  relapses;  the 
mildest  quartan  will  relapse  time  after  time  (James). 


MALARIA  yy 

Ouinine  eiven  b\'  the  mouth  verv  often  does  not  e^^ldicate  the 
asexual  cvcle  in  the  marrow  and  spleen;  the  residual  parasites  become 
immune;  the  longer  the  asexual  cycle  persists,  the  easier  it  acquires 
immunity  against  the  drug,  consequently  large  doses  must  be  given 
to  eradicate  the  disease. 

The  crescent  body  of  subtertian  malarial  infections  exhibits  no 
amoeboid  movements,  has  a  very  crescentic  shape,  contains  needle- 
shaped  h^emozoin  particles  somewhat  centrally  placed,  and  shows  a 
thin  circular  outline  of  the  damaged  red  cell  outside  it. 

Rarely  twin  crescents  may  be  seen  within  one  red  cell.  These  cell 
membranes  are  better  made  out  in  stained  specimens. 

When  the  crescent  is  young  the  hiemozoin  particles  are  scattered. 

When  the  crescent  is  mature  the  ha^mozoin  particles  are  concentric. 

\\^hen  the  crescent  is  effete  the  protoplasm  shows  vacuolation,  e.g., 
degeneration. 
■    The  hiemozoin  can  be  dissolved  by  weak  solutions  of  ammonia. 

in  the  male  the  protoplasm  is  hyaline  and  the  ha?mozoin  loosely 
arranged ;  the  protoplasm  stains  more  deeply  ;  the  nucleus  is  larger. 

In  the  female  the  protoplasm  is  faintly  granular,  the  ha?mozoin 
more  concentrated  and  centrally  placed.  The  protoplasm  stains 
faintly,  the  nucleus  smaller. 

llie  early  forms  seen  in  the  spleen  and  bone  marrow  about  the 
fourth  day  of  a  subtertian  malarial  attack  are  rarely  seen  in  the 
peripheral  blood  until  they  are  mature,  which  is  about  seven  davs  later. 

Some  of  the  crescents  outside  the  body  become  oval  or  spherical 
and  throw  off  microgametes  like  the  large  spherical  parasite;  the 
remaining  central  portion  breaking  up  is  carried  awav  bv  phagocvtes 
when  the  microgametes  have  become  separated. 

Just  before  the  filaments  are  thrown  out  the  agitation  of  the  hyaline 
sphere  becomes  intense.     These  are  the  male  sex  cells. 

The  granular  spheres  do  not  give  off  these  filaments  or  micro- 
gametes because  they  are  the  female  sex  cells. 

In  the  parasites  other  than  the  subtertian  ones  the  large  spherical 
parasites  act  in  a  similar  way,  with  the  exception  that  they  are  never 
crescent-shaped. 

Ross  has  shown  that  the  blood  must  come  in  contact  with  the  air 
for  these  changes  to  take  place  in  the  male  sex  cells.  Adding  a  little 
moisture  will  hasten  the  process.  Both  of  these  factors,  air  and 
moisture,  can  be  added  by  gently  breathing  on  the  slide  before  adjust- 
ing the  cover  slip,  the  male  sex  cells  of  course  being  mature. 

THROUGH  THE  ANOPHELIN^E. 

When  mature  crescents  are  taken  up  by  some  of  the  Anophelina?, 
they  become  transformed  into  male  or  female  sex  cells,  the  filaments 


78  DISEASES  DUE    TO    PROTOZOA 

of  the  male  cell  break  up,  one  filament  bulls  and  bores  its  way  into 
the  granular  or  female  sex  cell.  Where  this  iilament  or  microgamete 
disappears  inlo  the  female  cell  a  small  minute  papilla  is  thrown  out  to 
meet  the  oncoming  microgamete.  No  second  filament  can  enter,  no 
matter  how  energetical Iv  it  attacks  the  impregnated  cell.  Later  this  cell 
becomes  oval,  elongated  lanceolate,  and  finally  a  vermicular  form,  the 


a  h  c  d  e 

Stages  of  development  of  peinicious  or  malignant  terlian  pirasi'es  in  the  intestine  of 
Anopheles  maadipennis.  (After  Grassi.)  a,  macrogametocyte  (crcsceni)  still  attached  to  human 
blood  ci'fpuscles;  b,  macrogametocyte  (sphere)  half  an  hour  after  ingestion  by  ihe  musquiio  ; 
c,  microgametoc>te  (crescent)  attached  to  the  blood  corpuscle  ;  d,  microgametocyte  (sphere) 
half  an  hour  after  ingestion  ;  the  nucleus  has  divided  several  times ;  e,  micrugametes  attached  to 
the  residual  body  (polymitus  stage). 

anterior  end  becomes  pointed  and  hyaline,  the  posterior  end  broad 
and  granular  as  a  result  of  the  presence  of  the  hiemozoin.  The 
vermiculc  then  moves  about,  and  is  now  called  the  Ookinet.  This  can 
pass  through  a  red  or  white  cell.  The  ookinet  now  passes  through 
the  wall  of  the  mosquito's  stomach  and  the  delicate  basement  mem- 
brane of  the  stomach  wall,  and  lodges  amongst  the  longitudinal  and 


i:^* 


^m-| 


Ookinete  of  the  malignant  tertian  parasite  in  the  stnmsich  of  ^/top/ie/es  macu/ipe/i>ir's,  thuiyAwo 

hours  after  ingestion  of  blood.     (After  Grassi.) 

transverse  muscle  fibres  between  the  inner  membrane  and  the  outer- 
coat  of  the  stomach  wall.  Here  it  grows  for  a  few  days,  becomes 
spherical,  accjuires  a  capsule,  and  by  its  increasing  size  bulges  inwards 
the  stomach  wall,  it  is  now  an  Oocyst.  Spherical  daughter  cells  are 
formed  within  it.  Around  these  numerous  spindle-shaped  nucleated 
bodies  are  formed,  giving  it  the  appearance  of  an  apple  studded  with 
needles.  The  spherules  disappear  and  the  spindles  remain  loose  in 
the  capsule,  and  are  now  known  as  sporosoites.  In  about  one  week 
ihe  capsule  ruptures  and  discharges  its  contents  into  the  body  cavity 


MALARIA 


79 


of  the  mosquito,  leaving  there  probably  by  the  blood,  and  ultimately 
reaching  the  three  lobed  salivary  glands  which  communicate  with  the 
base  of  the  proboscis  by  means  of  a  long  duct.     The  parasites  may  be 
seen  in  the  cells  of  the  salivary  glands  and  in 
the  ducts.     The  parasite  is  now  ready  to  enter 
man  when  the  mosquito  bites  him. 

SUMMARY  OF  COMPLETE  LIFE-CYCLE. 

Sporozoites  enter  human  blood  corpuscles, 
where  they  exhaust  the  Hb.,  form  pigment, 
become  mature,  and  develop  into  either — 

(i)  Schisonts,    which    are    the    segmented 
and  rosette  forms. 

.  Section  of  the  stomach  of  an 

The     hfemozom     concentrates,     mero-    Anopheles,  wiih  cysts  (oocysts) 

zoites     form,      burst     the     red     cell     and      ofthe  malignant  tenian  parasite, 

(After  Grassi.) 

enter  fresh  ones,  only  to  begin  again 

the  endogenous  life-cvcle.  This  is  k'nown  as  the  asexual  stage 
of  schizogony. 
(2)  Gaiuetes.  These  are  crescents 
in  the  subtertian  form, 
spherical  bodies  in  the  ter- 
tian and  quartan  forms. 
There  are  male  and  female 
sexual  cells,  which  become 
dififerentiated  in  the  mos- 
quito. Microgametes  break 
ofif  from  the  male  and  im- 
pregnate tb.e  female  cell  or 
macrogamete.  This  impreg- 
nated    female     is     now     the 


ay  got  e 


It   begins   to   move 


and  is  now  an  ookinet.  It 
rests  in  tiie  stomach  wall, 
forms  a  capsule,  and  is  now 
an  oocyst.  It  divides  into 
daughter   cells   and    residua' 


Four  dififerent  sporulation  stages  of  malarial 
parasites  from  Anoplieles  tiiacu/ipeittiis,  much 
magnified,  a-c,  of  the  malignant  tertian 
parasite  ;  a,  four  lo  fcur  and  a  half  days  afier 
sucking  ;  b  and  c,  five  to  six  days  after  suck- 
ing ;  d,  of  the  tertian  parasite,  eight  days 
after  sucking.     (After  Grassi.) 

bodies.     The  daughter  cells 

produce  around  themselves   needle-like  bodies,   perhaps   io,ooa 

in  one  cysf,  which  become  sporosoites. 

The   oocyst   ruptures,    the   sporozoites   reach   the  bod\-   cavitv,    and 

ultimately   the  salivary  glands,   and  are  injected   into  man   along  the 

proboscis.     These    become    schizonts    in    his    blood,    and    renew    the 

endogenous  cycle  of  sporogony. 

It  is  suggested,   but   not   proved,    that   the   mosquito   mav    live    in 


■8o  DISEASES  DUE    TO    PROTOZOA 

A-ertebrates  other  than  man,  or  probably  the  mosquito  may  infect  its 
own  eggs,  and  thus  hand  down  the  infection  without  tlie  human 
element  being  present.     This  has  not  been  demonstrated. 

CHARACTERISTICS  OF  THE   MALARIAL  PARASITES. 

(Alodihed  after  Manson  and   Mannaberg.) 

For   brevity    in    this    statement    "  O  "    will    mean    Quartan,    "  T  " 
Tertian,  and  "  S-T  "  Subtertian. 

DURATION  OF  DEVELOPMENT. 

O.     72  hours. 
T.     48  hours. 
S-T.     36  to  48  hours. 

MOVEMENT. 

Q.     Slight  movement  in  the  immature  forms. 
T.     Active  amoeboid  movement  in  the  immature  forms  and  also 
in  the  middle-aged  forms. 
S-T,     Active  movement;  remains  present  in  the  pigmented  stage. 

H^EMOZOIN. 

O.     Coarse  grains;  little  or  no  movement. 

T.     F"iner  grains  in  immature  forms;  often  in  the  larger  actively 
swarming. 

MAXIMUM  SIZE. 

Q.     The  size  of  a  red  blood  corpuscle. 
T.     Ditto,  sometimes  a  little  larger. 
S-T.     Half  to  two-thirds  the  size  of  a  red  cell, 

FORM  OF  SEGMENTATION. 

O.     Daisy    form;    the    single    spores    roughish,     \\\\.\\     distinct 

nucleolus, 
T,     Sunflower     or     grape-like     spores,     single,     round,     small, 

nucleolus  rarely  seen. 
S-T.     Irregular  heaps. 

NUMBER  OF  MEROZOITES. 

Q,     6-12. 

T.     15-20,  often  less. 
S-T.     10-12,  rarely  15-16, 

FORM  OF  GAMETOCYTE. 

O.     A  sphere. 

T.     A  sphere. 

S-T.     A  crescent. 


MALARIA  8i 

ALTERATIONS   IN   INFECTED   BLOOD    CORPUSCLES. 

Q.     The  red  blood  corpuscles  are  little  discoloured,  and  are  not 

materially  altered  in  size ;  some  appear  smaller. 
T.     The  red  corpuscles  are  often   hypertrophied  and   have   lost 
colour,  it  may  be  completely.     Schijfifner's  dots  in  deeply 
stained  specimens. 
S-T.     The  red  blood  corpuscles  shrink  frequently ;  they  are  dark, 
or  may  be  perfectly  colourless. 

RELATIVE  NUMBER  OF  PARASITES  SEEN  IN  PERIPHERAL 
AND  VISCERAL  BLOOD. 

Q.     Parasites  seen  in  peripheral  circulation  throughout  the  whole 
cycle,  and  in  as  great  numbers  as  in  visceral  blood. 

T.     Parasites    seen    in    peripheral    blood    throughout    the    whole 

cycle,  but  not  in  such  large  numbers  in  visceral  blood. 

S-T.     An    enormously    greater    number    of    parasites    present    in 

internal  organs  as  compared  with  peripheral  blood.     The 

latter  part  of  the  cycle  takes  place  in  internal  organs  only. 

INFLUENCE  OF  QUININE. 

Q.     Causes  disappearance  of  parasites  readily. 
T.     Ditto. 
S-T.     Causes  disappearance  of  parasites  less  readily. 

LIABILITY  OF  RECURRENCE  OF  PARASITE  AFTER  LEAVING 
INFECTIVE  REGIONS. 

Q.     Liability  persists  for  a  very  long  period. 
T.     Liability  persists  for  a  long  period. 
S-T.     After  a  few  months  less  liability  to  recurrence. 

THE  MOSQUITO. 

It  does  not  follow  that  if  there  are  Anophelin^e  that  there  is  malarial 
fever,  e.g.,  England,  Epping  Forest  in  particular,  harbours  many  of 
these  mosquitoes,  but  there  is  no  malaria  in  consequence  because  the 
parasite  is  absent.  Again,  if  there  are  none  of  these  mosquitoes  there 
cannot  be  any  new  cases  of  malaria  if  the  parasite  is  brought  in  bv 
carriers. 

If  there  is  an  attack  of  malarial  fever  where  there  are  no  mosquitoes 
it  is  because  the  patient  has  been  previously  bitten  elsewhere. 

For  example,  cases  have  arisen  after  weeks  at  sea  owing  to  the 
climatic  changes  reducing  the  resistance  of  the  patient  and  giving  the 
parasites,  lying  in  the  spleen  probabl}-,  a  new  opportunity  to  do 
mischief. 

Where  mosquitoes  exist  the  temperature  must  be  favourable  for  rhe 
6 


82  DISEASES  DUE    TO    PROTOZOA 

development  of  the  parasitic  oocyst  in  the  body  of  the  mosquito.  If 
it  is  below  i5°-i6°  C.  no  further  development  is  said  to  take  place. 
L.  malarias  is  said  to  require  the  highest  temperature,  P.  vivax  the 
lowest,  and  P.  malarise  will  develop  at  low  or  medium  temperatures. 
These  differences  may  account  for  the  unequal  distribution  of  the 
parasites  and  for  their  lesser  danger  in  sub-tropical  and  temperate 
climates. 

For  details  of  the  habits,  &c.,  of  mosquitoes,  see  article  at  the  end 
of  the  present  one. 

MAN. 

Man  is  the  third  essential  factor  for  the  spread  of  malaria ;  without 
him,  as  far  as  is  known,  malaria  cannot  exist. 

The  native  population  in  the  tropics  forms  the  great  reservoir  of 
parasites,  but  Europeans  may  also  carry  large  numbers  of  gametocytes. 

A  new  district  should  always  be  investigated  with  regard  to  malaria 
and  the  following  facts  ascertained  :  — 

(i)  The  diagnosis  of  the  causative  parasite. 

(2)  The  population  of  the  area  under  consideration. 

(3)  The  average  number  of  infected  persons,  ascertained  by  the 
spleen  rate. 

(4)  The  average  number  of  persons  having  gametocytes  in  the 
blood. 

(5)  The  species  of  Anophelinse  and  their  breeding  places. 

(6)  The  species  which  carry  the  parasite. 

(7)  The  species  in  which  the  parasite  is  found. 

(8)  The  number  of  Anophelines  in  the  infected  area. 

DISTRIBUTION  AND  CLIMATOLOGY. 

Malaria  is  most  prevalent  in  the  region  of  the  Equator,  63°  N. — ■ 

Regions  that  were  once  deadly  may  become  salubrious,  e.g., 
England,  Germany,  Austria-Hungary.  On  the  contrary,  countries 
once  free  may  become  infected,  e.g.,  Mauritius,  which  was  said  to  be 
infected  during  the  sixties  of  last  century  by  the  introduction  of  carry- 
ing mosquitoes  (Ross). 

The  West  Coast  of  Africa,  from  Senegal  to  the  Congo,  is  perhaps 
the  worst  malarial  country  in  the  world. 

India  is  heavily  infected,  especially  about  the  swampy  lands  at  the 
foot  of  the  Himalayas. 

It  is  also  found  in  the  following  countries  :  Borneo,  Arabia,  Syria, 
Siam,  China,  Western  Australia,  New  Guinea,  Solomon  Islands, 
Bismarck  Archipelago,  Central  America,  West  Indies,  Mexican  Gulf, 
the   north   of   South   America,    Brazil,    Paraguay,    Bolivia,    Colombia, 


MALARIA  83 

Peru,  Chili,  many  of  the  Southern  States  of  Xorth  America,  Russia, 
Italy,  Greece,  Turkey,  Austria-Hungary,  Southern  France,  even 
amongst  the  soldiers  of  the  present  War.  In  Switzerland,  along  the 
Rhine  in  Germany.     Some  parts  of  Sweden. 

For  malarial  epidemics  there  must  be  malarial  parasites,  carrying 
mosquitoes,  man,   heat  and  moisture. 

High  altitudes  and  strong  winds  diminish  its  prevalence. 

Malaria  does  not  exist  in  :  — 

The  Seychelles,  Indian  Ocean,  Fiji,  Society  and  Friendly  Islands, 
Southern  Pacific,  Barbados  and  St.  Helena  in  the  Atlantic. 

Where  malaria  is  prevalent  children  tend  to  become  immune  about 
the  twelfth  year  (Ross). 

PATHOLOGY. 

The  febrile  phenomena  are  explained  b}-  various  malarial 
products  :  — 

(i)  Toxins  that  act  on  the  heart  controlling  centre. 

(2)  Haemolytic  toxins. 

(3)  Toxins  acting  on  the  innervation. 

Blood  serum  taken  before  a  rigor  and  passed  through  a  Berkefeld 
filter  will,  when  injected  into  a  healthy  man,  cause  a  febrile  paroxysm 
resembling  malaria  (Daniels). 

The  heat  output  during  the  cold  stage  of  an  attack  is  diminished, 
but  the  causative  metabolic  changes  are  but  little  known. 

The  urine  is  increased  during  this  stage,  probably  due  to  the  con- 
traction of  cutaneous  vessels  and  increased  B.P.  internally.  The 
specific  gravity  is  raised  as  a  result  of  the  increased  metabolism  caused 
by  the  toxins.  The  colour  is  dark  and  the  acidity  increased.  Nitrogen 
is  in  excess  owing  to  urea.  The  salts  are  all  increased,  except 
phosphates,  which  are  diminished  during  an  attack,  and  increased 
during  the  intermission,  therefore  phosphoric  acid  is  retained  during 
the  attack.  The  excretion  of  iron  is  increased  in  the  h^mozoin  and 
hasmosiderin.     The  increase  commences  just  after  the  attack. 

There  may  be  a  considerable  quantity  of  urobilin  excreted,  and  the 
indigo  blue  may  be  increased.     To  test  for  urobilin  :  — 

Add  to  urine  equal  parts  of  ZnSo4  solution  (ZnSo4  10,  absolute 
alcohol,  90).  Shake  the  mixture.  Add  a  few  drops  of  lugol,  stir  and 
filter.     Fluorescence  equals  urobilin. 

The  diazo  reaction  is  present  in  5*5  per  cent,  of  cases. 

During  the  intermission  the  quantity  of  urine  is  diminished,  but  the 
nitrogen  keeps  up. 

During  convalescence  there  is  polyuria  with  low  specific  gravity, 
especially  in  subtertian  cases. 


84  DISEASES  DUE    TO    PROTOZOA 

The  jcBces  show  increased  excretion  of  bile  and  iron,  both  from 
blood  destruction.     Stercobilin  is  increased. 

The  sweat  has  a  peculiar  odour  and  is  toxic  to  rabbits. 

Goose  skin  may  be  caused  by  some  malarial  toxin  acting  on  un- 
striped  muscle,  affecting  the  erector  pilorum. 

Hcemozoin  is  the  black  dust-like  grains  of  pigment  formed  from 
haemoglobin  and  distributed  over  the  body  after  the  rupture  of  the 
red  cells.  Phagocytes  remove  it  to  the  connective  tissue,  e.g.,  the 
liver  and  spleen.  It  is  soluble  in  alkalies,  entirely  and  rapidly  in 
ammonium  sulphide,  but  not  in  water,  alcohol  or  acids.  It  contains 
an  organic  compound  of  iron  which  will  not  give  the  Berlin  blue  re- 
action. Eventually  it  disappears  from  the  body,  but  how  is  not 
known . 

It  is  peculiar  to  diseases  caused  by  malarial  parasites  except 
melanotic  tumours,  but  in  the  latter  instances  it  is  never  seen  in  the 
blood-vessels.  Intravascular  black  pigment  is  pathognomonic  of 
malaria.  It  is  most  abundant  in  the  splenic  vein  and  lymphatic 
glands  at  the  hilum  of  the  liver. 

HcBmosiderin  is  a  yellow  pigment  found  as  yellow  granules  in  the 
parenchyma  cells  of  the  liver,  spleen,  kidneys,  pancreas,  bone-marrow, 
capillary  epithelium,  and  less  frequently  in  the  leucocytes. 

It  contains  an  inorganic  compound  of  iron  which  gives  the  Berlin 
blue  reaction  (ammonium  sulphide  and  double  cyanide  of  iron  and 
potassium).     It  is  insoluble  in  alkalies,   acids  and  alcohol  (Manson). 

It  is  not  peculiar  to  malarial  diseases,  but  may  occur  in  any  where 
there  has  been  marked  blood  destruction,  as  in  haemoglobinuria, 
pernicious  ana&mia,  extensive  burns  and  toxic  poisoning  by  such  agents 
as  potassium  chlorate  and  pyrogallic  acid. 

The  liver  converts  the  free  haemoglobin  into  bile  pigment,  which, 
when  in  excess,  overflows,  as  it  were,  causing  bilious  diarrhoea  and 
vomiting;  consequently  polycholia  is  a  constant  feature  of  malaria. 
The  yellow  tinging  of  the  skin  and  sclerae  may  be  due  to  free  hemo- 
globin and  not  to  cholasmia  as  a  result  of  bile  absorption  as  once 
commonly  believed  (Manson).  This  yellow  pigment  is  probably  pre- 
cipitated haemoglobin,  stored  up  and  waiting  to  be  worked  off  by  a 
busy  liver.  Should  the  haemoglobin  go  beyond  this  it  overflows,  and 
then  we  have  haemoglobinuria. 

The  red  cells. — The  body  (150  lbs.)  contains  about  25,000,000,000,000 
red  cells.  To  examine  all  these  under  the  microscope  at  the  quickest 
rate  would  take  over  1,000  years  (Ross). 

In  severe  infections  12  per  cent,  are  infected,  i.e.,  2,000,000,000,000. 

If  only  I  in  100,000  corpuscles  are  infected,  i.e.,  250,000,000,  there 
will  be  but  little  manifested  of  the  disease  (Ross). 


MALARIA  85 

Daniels  says  that  600,000,000  red  cells  could  be  infected  without 
the  victim  having  "  fever."  It  has  been  estimated  that  300,000,000 
are  required  to  produce  each  degree  F.  rise  in  the  body  temperature 
due  to  a  malarial  attack.  Anything  under  this  number  has  been  called 
"  latent  malaria." 

The  different  pictures  caused  by  the  various  malarial  parasites  will 
be  given  in  a  table  later. 

The  marked  blood  destruction  during  an  attack,  especially  in  the 
subtertian  variety,  is  considerable,  but  it  is  made  up  very  quickly 
during  the  intermission,  so  that  the  number  of  red  cells  may  be  almost 
normal  by  the  time  of  the  second  paroxysm  in  tertian  and  quartan 
cases.  Unafifected  red  cells  become  pale,  vary  in  shape  (poikilocy- 
tosis),  sometimes  with  megaloblasts  (polychromatophilia),  basic  and 
granular  degeneration  with  normoblasts. 

OligocythcBmia  is  always  present.  If  i  per  cent,  of  the  red  cells 
is  attacked  and  contains  a  parasite,  we  should  expect  a  reduction  of 
I  per  cent,  of  total  red  cells.  If  every  twentieth  cell,  then  5  per  cent, 
of  the  total  destroyed,  and  so  on,  but  it  is  not  so.  Only  after  one 
paroxysm  of  fever  the  drop  may  be  from  5  per  cent,  to  10  per  cent., 
and  after  some  one  pernicious  attack  I-  to  one  million  per  c.c.  of  blood 
will  be  destroyed,  and  if  the  pernicious  attacks  continue  the  count 
may  be  about  one  million  instead  of  5|-  millions. 

The  Hb.  value  of  the  remaining  corpuscles  goes  doMm  10  per  cent., 
20  per  cent,  to  50  per  cent,  below  normal. 

The  volume  of  blood  is  also  diminished  as  demonstrated  post 
mortem . 

The  venous  system,  apart  from  that  of  the  portal  system,  spleen 
and  liver,  may  be  markedly  empty.  Blood  may  not  flow  freely  from 
the  pricked  finger.  The  writer's  blood  during  a  pernicious  attack  in 
Colombia  was  so  viscid  and  blackish  that  hcemocvtometer  pipettes 
were  repeatedly  blocked  and  no  count  could  be  made. 

Anaemia  during  first  attacks  is  marked,  but  rapidly  replaced. 

Anaemia  during  the  following  attack  is  less  marked  and  less  rapidlv 
replaced . 

The  white  cells.  The  leucocytes  are  at  first  increased  during  the 
rigor,  8,000  to  30,000  in  some  cases,  but  thev  markedly  diminish, 
causing  a  leucopsenia  with  a  ratio  of  i — 500  or  600.  In  pernicious 
malaria  there  may  be  leucocytosis.  Mononuclears  are  more  marked 
during  the  leucopasnia,  and  persist  for  some  time  after  the  fever  has 
subsided.  It  is  a  useful  factor  for  diagnosis  when  the  patient  is  seen 
after  the  attack.  The  increase  is  relative  and  absolute;  15  per  cent, 
increase  suggests  malaria.  It  is  also  present  in  other  protozoal 
infections. 


86  DISEASES  DUE    TO    PROTOZOA 

Phagocytosis  is  carried  on  more  by  the  large  mononuclear  elements 
and  transitional  leucocytes  than  by  the  polys.  A  phagocyte  may 
engulf  a  red  cell  and  its  contained  parasite. 

Vacuolization  and  a  reduced  staining  power  have  been  noticed. 

Myelocytes   have   sometimes   been    found    in    subtertian   cases   (Da' 
Costa). 

MORBID  ANATOMY. 

(i)  In  acute  vialaria  of  P.  malarice. 

The  parasite  does  not  especially  accumulate  in  any  one  organ. 

The  spleen  is  enlarged,  not  soft  or  very  melanotic. 

The  liver  and  bone-marrow  may  be  markedly  melanotic. 

There  are  parasites  in  the  spleen  and  the  blood,  but  not  in  the  brain. 

(2)  In  acute  malaria  of  P.  vivax. 

Death  may  be  caused  in  rare  cases  by  coma,  hsemoglobinuria  with 
pigmentation  of  the  bone-marrow,  spleen  and  liver.  The  spleen  is 
enlarged.     Its  contained  blood  shows  large  numbers  of  parasites. 

The  kidneys  and  colon  are  inflamed. 

The  endothelial  cells  of  the  brain  are  swollen  and  contain  pigment 
(Ewing). 

(3)  In  the  acute  malaria  of  L.  malarice. 

The  organ  chosen  for  sporulation  suffers  most,  and  produces  the 
symptoms  giving  the  character  of  that  particular  type  of  the  disease. 
The  organ  attacked  principally  may  be  the  brain,  intestine,  heart  or 
pancreas. 

Macroscopic. 

The  body  is  pale,  yellowish  in  white  races;  the  heart  muscle  pale 
and  flabby;  ecchymoses  sometimes  in  the  epi-  and  endo-cardium. 

The  lungs  may  be  normal  or  congested,  rarely  sclerosed. 

The  liver  is  enlarged,  dark  brown  to  slate  colour  on  section,  soft 
and  congested. 

The  gall-bladder  is  full  of  dark  bile. 
The  spleen   is  enlarged,   capsule  tense;  on  section,   deep  brown   to 
black  in  colour. 

The  stomach  and  intestines  are  not  affected,  except  in  choleraic 
forms,  when  the  mucous  membrane  is  congested  (except  about  Peyer's 
patches  and  the  solitary  glands)  with  blood-stained  contents,  flakes  of 
mucous  and  dark  pigmentation  due  to  h^mozoin  readilv  demonstrated 
by  the  microscope. 

The  lymphatic  glands  are  swollen. 

The  pancreas  is  normal  or  in  a  condition  of  hcemorrhagic  pan- 
creatitis. 

The  suprarenals  are  congested. 

The  kidneys  are  normal  or  congested,  with  punctiform  haemorrhages 
in  the  pelvis,  and  cloudy  swelling  in  the  parenchyma. 


MALARIA  Sy 

The  bone-marrow  is  hypercemic  and  chocolate-brown  in  colour. 

The  brain  is  normal,  or  in  the  cerebral  type  of  the  disease  one  finds 
oedema,  hyper^emia  of  leptomeninges;  broM'n  or  black  pigmenta- 
tion of  cortex  and  punctiform  haemorrhages  in  the  white  matter  under 
the  cortex. 

The  spinal  canal  is  similar  to  the  brain. 

The  retina  may  show  numerous  haemorrhages. 

Microscopic. 

Parasites  are  found  in  the  blood  of  the  heart,  spleen,  bone-marrow, 
capillaries  of  brain,  intestine,  pancreas,  &c.,  but  the  types  are  not 
differentiated  clearly  after  death.  They  shrink  considerably.  The 
mononuclears  show  pigment  granules.  The  polys  show  phagocytosis 
in  a  small  degree.  Macrophages  rnay  be  seen  from  the  internal  organs 
containing  parasites  and  red  cells. 

The  heart  muscle  is  loaded  with  hasmosiderin  and  the  capillaries 
with  parasites. 

The  lungs  contain  parasites  in  all  stages  of  development  with  pig- 
mented macrophages  and  leucocytes.  The  pneumococcus  is  always 
present,  and  perhaps  forms  a  double  infection. 

The  capillaries  of  the  liver  are  enlarged  and  swollen  by  the  endo- 
thelial cells  loaded  with  pigment,  and  filled  with  blood  cells  containing 
parasites  and  leucocytes  with  pigment. 

The  perivascular  h-mphatics  are  swollen. 

The  liver  cells  are  compressed  between  dilated  capillaries  and 
contain  hasmosiderin  ar.:l  bile  pigment.  Rarelv  there  are  localized 
patches  of  necrosis. 

The  portal  canals  are  infiltrated  with  red  cells  containing  parasites. 

The  red  cells  of  the  spleen  show  schizonts  and  crescents. 

The  leucocytes  and  macrophages  show  pigment. 

The  kidneys  show  pigmentation  of  the  capillarv  walls  of  the 
glomeruli.  Parasites  are  rare  here,  but  plentiful  between  the  tubules. 
Phagocytes  with  pigment  and  parasites  are  not  uncommonlv  seen  here. 
The  cells  of  the  glomeruli  degenerate  and  are  cast  off  into  the  capsule; 
the  epithelial  cells  of  the  convoluted  tubules  degenerate  and  are  cast 
off  into  the  lumen. 

The  suprarenals  show  irregular  areas  of  vasodilatation,  full  of  red 
cells,  many  of  which  contain  parasites. 

The  same  may  be  said  of  the  capillaries  of  the  abdominal  fat. 

The  bone-marrow  is  chocolate-coloured  in  the  small  bones  and 
brownish  red  in  the  long  ones.  It  is  soft,  diffluent,  contains  sporu- 
lating  parasites  and  crescents. 

The  brain  in  cerebral  cases  has  the  capillaries  full  of  sporulating 
parasites,   mononuclear  elements,   macrophages  containing  dead  para- 


88  DISEASES   DUE   TO   PROTOZOA 

sites.  Nissl's  bodies  may  be  damaged  and  disappear  or  degenerate 
only.  There  may  be  degeneration  of  the  neurofibrils.  The  puncti- 
form  haemorrhages  are  due  to  the  diapedesis  of  apparently  normal 
red  cells. 

(4)  In  the  chronic  malaria  of  P.  vivax. 

(There  are  no  records  of  post-mortem  findings  in  chronic  malaria 
due  to  P.  malarise.) 

Those  of  P.  vivax  are  ;  — 

Enlarged  spleen,  which  is  firm,  dark,  containing  parasites  and 
pigment  in  the  endothelial  cells  about  the  Malpighian  bodies.  Some 
haemosiderin. 

The  liver  revealed  nothing  macroscopical,  but  microscopically  pig- 
ment could  be  seen  collected  in  the  large  intracellular  masses  in  the 
portal  canals.     The  macrophages  contained  pigment. 

The  bone-marrow  was  slightly  pigmented,  showing  a  few  endo- 
thelial cells  with  black  pigment. 

In  one  case  (Ewing)  the  patient  was  ill  for  twelve  months,  and  died 
from  endocarditis  three  months  after  the  last  malarial  attack. 

(5)  In  chronic  malaria  due  to  L.  malarice. 

The  spleen,  liver  and  bone-marrow  are  the  parts  always  affected. 

Spleen,  enlarged,  firm,  slaty  colour,  depending  upon  the  amount 
of  contained  pigment,  signs  of  old  perisplenitis,  e.g.,  thickened  cap- 
sule; Malpighian  bodies  stand  out  boldly,  as  they  are  enlarged  and 
non-pigmented. 

The  capillaries  are  dilated,  and  are  separated  by  splenic  pulp  or 
connective  tissue  containing  giant  cells. 

The  pigment  may  be  scattered  diffusely,  but  is  generally  collected 
around  follicles  or  extracellular,  and  contained  in  lymphatics  of 
arterioles  or  septa. 

Liver,  large,  hard,  pigment  not  always  present,  seen  at  times 
gathered  around  the  periphery  of  lobules;  later  the  pigment  is  peri- 
vascular and  finally  disappears.  The  capillaries  or  lymph  spaces  are 
dilated,  and  by  their  pressure  cause  atrophy  of  the  liver  cells;  the 
hepatic  cells  may  be  seen  repairing  the  damage  done. 

Bone  marrow,  usually  pigmented  and  of  a  chocolate  colour  in  the 
small  bones,  reddish  in  the  long  ones.  The  change  of  colour  is  due 
to  replacement  of  the  fat  by  vascular  tissue. 

(6)  In  malarial  cachexia. 

It  may  follow  a  few  acute  attacks,  or  more  commonly  coma  as  a 
sequel  to  chronic  malaria. 

Anemia  is  marked.     Oedema  of  the  ankles  and  abdomen  frequent. 
The  spleen  is  enormously  enlarged,  the  liver  also. 
The  bone-marrow  is  yellow,  sclerotic  or  gelatinous. 


MALARIA  89 

Parasites  may  be  found  or  may  be  absent. 

Sometimes  there  are  amyloid  changes  in  the  kidneys  with  parenchy- 
matous nephritis,  associated  more  rarely  with  amyloid  changes  in  the 
intestine,  spleen  and  liver. 

SYMPTOMATOLOGY. 

A  typical  febrile  malarial  attack. 

In  all  types  of  malarial  fever  there  are  definite  attacks  every  twenty- 
four,  forty-eight,  or  seventy-two  hours.  Each  attack  has  four  stages, 
followed  by  an  interval  of  apyrexia. 

(i)  Premonitory  stage. 

This  is  sometimes  absent. 

When  present  it  lasts  from  a  few  hours  to  a  few  days. 

There  are  :  Lassitude,  aching  of  bones,  headache,  anorexia,  yawn- 
ing, sometimes  vomiting. 

Two-thirds  of  actual  agues  take  place  between  midnight  and  mid- 
day, most  other  febrile  diseases  from  midday  to  midnight  (Manson). 

(2)  Cold  stage. 

This  lasts  about  an  hour. 

Teeth  chatter,  patient  shivers  and  shakes  from  head  to  foot. 
Wraps  himself  in  blankets  to  keep  himself  warm. 
Vomiting  may  be  distressing. 

The  features  are  drawn  and  the  skin  blue,  but  the  body  temperature 
may  be  several  degrees  above  normal  and  rapidly  rising. 

The  urine  is  abundant  and  passed  frequently.     Urea  is  increased 
Young  children  may  have  convulsions. 
Then  follows  the — 

(3)  Hot  stage. 

This  lasts  four  hours. 

There  are  waves  of  warmth,  intense  heat. 

Blankets  are  thrown  off;  there  is  a  desire  for  more  air. 

The  face  is  flushed,  pulse  rapid,  full  and  bounding. 

Headache  intense,  vomiting  frequent,   respirations  hurried. 

Conjunctivae  injected,   sometimes  erythematous  rash. 

Skin  dry  and  burning.  Body  temperature  40'6°  C. — 41 '0°  C. 
(104O— 106°  F.). 

Urine     scanty,      loaded     with     urea     and     chlorides.      Phosphates 
diminished. 

Bile  pigment  present  in  urine. 

Then  follows  the — 

(4)  Sweating  stage. 

This  last  from  two  to  four  hours. 

There  is  profuse  perspiration,  clothes  and  bedding  are  soaked. 


90  DISEASES   DUE   TO   PROTOZOA 

Fever  rapidly  declines.     The  urine  is  as  in  the  hot  stage. 

Distressing  symptoms  abate,  relief  comes,  patient  sleeps  readily. 

Temperature  may  fall  to  normal  or  sub-normal. 

Apart  from  weakness  the  patient  feels  well. 

The  whole  attack  lasts  from  six  to  ten  hours,  but  may  vary  much. 

A  similar  attack  takes  place  one,  two  or  three  days  later,  unless 
quinine  is  given  in  the  interval. 

The  spleen  enlarges  temporarily,  but  remains  slightly  larger  after 
each  attack.  In  frequent  attacks  the  spleen  may  be  enlarged  enor- 
mously, permanently  and  accompanied  by  a  cachectic  state. 

The  most  pernicious  fevers,  so  common  in  Africa,  are  most 
atypical ;  the  patient  may  reach  a  serious  condition  before  a  doctor  is 
consulted. 

The  rise  of  temperature  is  caused  by  the  discharge  of  malarial  toxin, 
when  the  red  cells  rupture,  and  not  because  of  the  parasites  being 
liberated  in  the  serum.  Between  attacks  the  young  parasites  are  grow- 
ing to  maturity  in  fresh  red  cells  to  cause  another  rise  of  temperature, 
when  the  latter  are  ruptured. 

There  are  continued  and  remittent  types  of  malarial  fevers,  when 
parasites  of  all  stages  may  be  met  with  in  the  red  cells. 

CLASSIFICATION. 

Acute  Malaria. 

13     .       ^       ,  j   Simple,  Triple, 

^     ■^  I    Double,  Mixed, 

D     .       T,    ,.  (   Simple.  Double, 

Benign  leniaii.  ...    \    ^       ^    .  ,         ,. 

**  ]    Irregular  subcontmuous, 

Malignant  or       Simplf^, 
Siihtertian.  Double, 

(Crescents.)        Irregular, 


-to" 


Do  not 
form  crescents. 


Remittent, 


typhoid. 

adynamic. 

bilious. 


Pernicious  with  general  symptoms,  e.g., 

Algide,  Diaphoretic, 

Hemorrhagic,  Scarlatiniform. 

Pernicious  with  local  symptoms,  e.g.. 

Cardiac, 
Pulmonary. 

Pulmonic, 

Pleuritic. 
Gastrointestinal, 

Choleraic, 

Dysenteric, 

Haemorrhagic  pancreatitis, 

Peritonitic. 


MALARIA 

Cerebrospinal, 
Comatose, 
Hyperpyrexia, 
Delirious, 
Tetanic, 
Eclamptic, 
Meningitic, 
Hemiplegic, 
Amblyopic, 
Bulbar, 
Cerebellar. 
Chronic  Malaria. 

Cachexia. 

CLINICAL  VARIETIES. 

Sitnple   Quartan  Fever  (Benign). 
The  parasite  is  P.  malariag. 
Its  cycle  is  seventy-two  hours. 


91 


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1 

Quartan  fever. 

At  first  the  parasite  is  a  small,  round,  clear  speck  in  the  invaded 
red  cell.     Its  amoeboid  movement  is  feeble. 

When  it  becomes  pigmented  all  amoeboid  movement  ceases. 

The  hasmozoin  it  carries  is  large  in  amount,  coarse  in  grain,  and 
is  seen  as  short  rods. 

The  segmented  or  mature  parasite  has  eight  to  ten  merozoites, 
symmetrically  arranged  "  daisy  "  fashion  around  the  block  of  black 
haemozoin. 

A  shining  nucleolus  can  be  seen  readily  in  the  centre  of  each  pear- 
shaped  segment. 

The  gametocyte  or  sexual  form  is  a  spherical  pigmented  body  like 
an  ordinary  parasite  that  has  escaped  whole  from  the  red  cell. 

The  hcemozoin  granules  may  show  very  active  amoeboid  movement. 

The  enclosing  red  cell  is  not  enlarged. 

When  mature  the  parasite  completely  fills  the  cell,  often  without 
any  ring  of  haemoglobin,  but  as  red  cells  vary  in  size  in  these  fevers, 
a  quartan  parasite  in  a  large  erythrocyte  may  resemble  a  tertian  parasite 
in  certain  stages  of  its  growth. 


92 


DISEASES   DUE   TO   PROTOZOA 


It  is  supposed  that  some  parasites  degenerate,  neither  segmenting 
nor  forming  gametes. 

The  various  stages  of  growth  and  the  segmented  "daisy"  body 
are  more  frequently  seen  in  the  peripheral  blood  than  those  of  other 
varieties. 

This  fever  was  formerly  common  in  England. 

It  is  more  common  in  temperate  than  tropical  climates. 

Cachexia  is  not  so  common  with  this  as  other  malarial  fevers. 

The  individual  attacks  are  very  amenable  to  quinine,  but  the 
parasites  are  more  difficult  to  kill  off  than  those  of  other  varieties 
(Manson). 

If  untreated  the  fever  is  supposed  to  exhaust  itself  and  die  out,  but 
spontaneous  cure  is  rare. 

Double,   Triple  and  Mixed  Quartan  Fevers. 

These  occur  when  there  are  two  or  three  families  of  the  same  kind 


TIME 

M     1 

:    M 

e: 

M     E 

:  M    E 

M 

c 

M 

e 

M 

C 

M 

E 

r' 

I03 
102 

to  1 

100 
99 
98 
97 

V 

\ 

K 

\ 

1 

1 

\ 

A 

V 

I 

V 

^ 

^ 

I 

N 

J 

f 

V 

\ 

^ 

l> 

Double  quartan. 


of  parasite  present.  There  is  a  daily  fever.  The  condition  is 
diagnosed  by  the  microscope  only.  The  rises  of  temperature  may  be 
unequal  for  each  family  of  parasites  present,  but  when  there  are  other 
varieties  of  malarial  parasites  the  condition  is  known  as  a  mixed  one, 
and  greater  differences  of  temperature  variation  may  be  noticed. 

Major  Donovan  records  one  case  in  which  he  found  the  three 
varieties  of  malarial  parasites.  This  seems  to  favour  Laveran's  view 
that  the  malarial  parasites  constitute  a  single  species  with  three 
varieties,  a  view  not  widely  held. 

Simple  Benign  Tertian  Fever. 

The  parasite  is  P.  vivax. 
The  cycle  is  forty-eight  hours. 

The  very  young  form  is  indistinguishable  from  that  of  the  quartan, 
but  later  one  sees — 

Much  more  amoeboid  movement. 


MALARIA 


93 


The  change  of  form  and  position  of  the  parasite  in  the  corpuscle 
from  time  to  time. 

That  it  pushes  out  and  retracts  pseudopodia. 

The  movement  is  suspended  when  the  concentration  of  haemozoin 
is  accomplished. 

The  haemozoin  particles  are  finer  than  cjuartan  and  have  more  active 
and  incessant  movement. 

There  is  hypertrophy  and  marked  decolorization  of  the  invaded  red 
cell,  which  may  be  twice  its  normal  size. 

The  rim  of  haemoglobin  becomes  almost  colourless. 

With  deep   Leishman's  stain   the   Hb.   shows  chromatophile  dots, 


TIME 

M 

E 

M 

e:   a 

A     Z 

M 

Z    t, 

A     E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

Tl 

M 

E 

M 

E 

M 

E 

f' 
105 

10"* 

I03 

J02 

101 

lOO 

99 

98 

97 

I 

\ 

1 

i 

[ 

^ 

\ 

\ 

1 

i 

, 

N 

\ 

1 

\ 

^ 

V 

^J 

V 

"^ 

V 

V 

•A 

s 

J 

V 

"* 

* 

V 

>r- 

-v 

>«' 

^ 

Simple  benign  tertian. 


"  Schiifner's  "  dots,  which  are  not  shown  by  quartan  or  sub-tertian 
parasites. 

The  segmented  body  has  sixteen  to  twenty  spherules,  like  a  cluster 
of  grapes  and  not  daisy  fashion.  One  or  two  particles  of  pigment 
can  be  seen  among  the  spherules.  These  latter  are  smaller,  smoother 
and  rounder  than  those  of  the  quartan, 

The  segmented  parasite  is  called  a  "  rosette  "  body. 

As  in  the  quartan  the  gametocyte  is  a  spherical  body,  but  much 
larger  than  the  quartan. 

This  parasite  is  the  commonest,  and  occurs  in  tropical  and  tem- 
perate climates. 

The  fever  resembles  that  of  the  quartan  type. 

Spontaneous  cure  is  more  likely  than  in  the  quartan  type. 

The  resulting  anaemia  is  more  readily  recovered  from  than  that  of 
quartan  malaria. 

Double  Benign  Tertian  Fever. 

This  is  the  same  as  the  above,  but  there  are  two  families  of 
parasites  maturing  on  different  days.  The  two  attacks  may  not  be 
equal  in  severity. 


94 


DISEASES   DUE   TO    PROTOZOA 


Irregular  Sub  continuous  Benign  Tertian  Fever. 

Parasites  may  mature  at  different  times  of  the  same  day,  thus  pro- 
ducing a  somewhat  continuous  fever  with  remission  and  exacerbations. 
In  this  respect  it  may  resemble  subtertian  fever. 

Irregularities  may  also  be  caused  by  a  mixed  infection  of  other 
types  of  malarial  parasites. 

Simple  Subtertian  Malarial  Fever. 

The  parasite  is  Laverania  malarise. 

The  cycle  is  probably  twenty-four  to  forty-eight  hours. 
These  are  crescent-forming,  and  all  are  malignant. 
The  subtertian  parasite  is  much  smaller  than  the  tertian  or  quartan, 
occupying  as  it  does  half  to  three-quarters  of  the  red  cell. 
The  early  unpigmented  stage  is  difficult  to  see. 
The  amoeboid  movements  are  very  active  at  first. 


TIME 

M     E 

.     M     E 

.      M     E 

M     i 

:   M   E 

M     E 

M 

E 

M 

E 

M 

E 

F° 
105 

1  04 

103 

I02 

1  0  1 

1  GO 

99 

96 

97 

I 

1 

\ 

1 

' 

> 

A 

\ 

A 

V 

\^ 

V^J 

V 

V 

'\ 

N, 

r 

-% 

/ 

r 

V 

V 

Double  tertian. 


The  parasite  settles  down  later  and  forms  small  colourless  rings. 

Multiple  infection  of  individual  cells  is  common,  much  more  than 
in  other  types,  owing  perhaps  to  the  enormous  number  present  at  the 
same  time. 

The  invaded  corpuscle  seems  to  be  filtered  out  by  the  capillaries  and 
small  arteries  of  the  deeper  viscera  and  bone-marrow ;  hence  few  are 
seen  in  the  peripheral  blood. 

The  segmented  form  is  very  rarely  seen  in  the  blood. 

It  has  ten  to  twelve  segments. 

The  invaded  cells  shrink,  become  darker,  sometimes  crenated  or 
folded,  when  they  are  known  as  "  brassy  "  bodies,  when  the  parasites 
may  be  made  out  as  small  minute  pale  rings. 

The  gametocyte  is  crescent-shaped,  and  in  this  is  unique. 

A  week  may  elapse  after  the  small  intracorpuscular  parasites  have 
been  seen  before  crescents  are  formed,  probably  not  until  the  pabulum 
has  been  exhausted  by  swarms  of  endogenous  parasites,   so  that  the 


Essentials  of  Tropical  Medicine. 


Tertian  Malarial  Parasite.     (Weight's  Stain.) 
(From  Webster's  Diagnostic  Methods.) 


Estwo- Autumnal  Parasite.     (Wright's  Stain.) 
(From  Webst  er  s  Diagnostic  Methods.) 


MALARIA 


95 


crescent  provides  for  life  and  growth  elsewhere,  e.g.,  in  the  mosquito. 
These  persist  in  the  circulation,  in  spite  of  heroic  quinine  treatment, 
from   two   to   six   weeks,    after   all  other   parasites   have   disappeared. 


Subteitian  malaria.      Periodicity  still  definite. 


TIME 

A.M 

P  M. 

A  M 

PM. 

A.M. 

PM 

A  M. 

P  M 

A  M. 

P  M. 

A    M 

RM. 

a.m|p.m| 

F° 
103 

1  02 

1  0  1 

1  OO 

99 

98 

97 

96 

n 

,      1^ 

\. 

/^ 

r 

]/ 

\ 

n 

\ 

Y 

r 

'        \ 

w 

\ 

\ 

r 

hi 

\ 

V 

I 

\ 

/ 

V 

\ 

V        J 

i 

\ 

r 

A 

V 

\      / 

w 

\ 

V 

M 

\ 

11 

\ 

Subtertian  malaria.     Periodicity  indefinite. 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

£ 

1  O  4 

1  03 

102 

1  0  1 

1  OO 

99 

98 

97 

A 

A 

1 

r 

A 

A 

/ 

/ 

\ 

V. 

^ 

-V 

w 

VI 

^ 

I 

A- 

V 

Subtertian  malaria  (untreated). 
Slight  fever  only.  No  definite 
periodicity.  Diagnosis  based  on 
blood   examination. 


TIME 

AM. 

P.M 

A.M. 

PM 

A  M. 

P.M 

A.M 

P.M. 

I06 
105 

1    O-T 

1  03 

1  02 

1  O  1 

1  00 

99 

98 

97 

A, 

1 

\ 

V 

/ 

^ 

,  1 

/ 

\ 

\ 

w 

\ 

V 

1/ 

\ 

• 

\ 

\ 

\ 

\ 

^.. 

yN 

s/ 

Severe  subtertian  malaria 
(treated). 


Quinine  given  very  early  may  stop  their  formation,  but  later  it  has 
no  effect  upon  them.  The  presence  of  crescents  is  usually  marked 
with  cachexia. 

It  is  common  in  all  tropical  regions.     In  the  sub-tropics  it  occurs 


96  DISEASES  DUE   TO   PROTOZOA 

in  the  late  summer  and  late  autumn,  and  hence  is  called  "  aestivo- 
autumnal  "  fever. 

It  has  been  noted  that  crescents  can  rarely  be  found  in  the  African 
subtertian  fevers,  but  when  these  patients  get  to  Europe  the  parasites 
can  more  frequently  be  found  (Manson). 

The  fevers  produced  by  the  subtertian  parasite  are  very  irregular, 
the  rigor  is  less  marked,  the  pyrexial  stage  more  prolonged,  while 
vomiting,  body  pains,  intestinal  disturbances  and  depression  are  more 
marked.  Relapses  are  much  more  frequent.  There  may  be  a  false 
crisis  preceding  the  true  one.  There  is  a  rapid  destruction  of 
corpuscles,  followed  by  a  marked  cachexia.  Grave  symptoms  may 
arise  at  any  time. 

Double  Subtertian  Fever. 

This  is  caused  by  two  broods  of  the  Laverania  malarise  parasite, 
and  has  symptoms  in  common  with  the  preceding  form. 

Irregular  Subtertian  Fever. 

This  is  caused  by  several  broods  of  L.  malarise  sporulating  at 
different  times,  causing  an  irregular  fever.  It  is  common  on  the  West 
Coast  of  Africa. 

Remittent  Subtertian  Fever. 

An  ordinary  attack  may  be  prolonged  or  two  attacks  may  be  con- 
tinuous, the  second  commencing  before  the  first  has  concluded. 

These  may  be  serious  at  any  time  or  may  become  pernicious. 

There  may  be  sleeplessness,  restlessness  or  delirium. 

The  liver  and  spleen  are  enlarged  and  tender. 

There  is  slight  dilatation  of  the  right  side  of  the  heart. 

Unless  drastically  treated  the  fever  may  resemble — 

(i)  Typhoid  fever  in  its  clinical  manifestations,  with  low  delirium, 
prostration,  dry  tongue,  liver  and  spleen  much  enlarged,  and 
melan^mia; 

(2)  Bilious  fever,  with  vomiting,  diarrhoea,  constipation,  jaundice, 
due  probably  to  the  absorption  of  modified  haemoglobin,  e.g.,  haema- 
phein ;  the  liver  is  much  enlarged.  There  is  much  blood  destruction, 
much  bile  formation,  and  sometimes  coma  and  death. 

(3)  Adynamic  fever,  with  tendency  to  haemorrhages,  local  gangrene, 
hasmoglobinuria,  great  weakness,  nervous  depression,  muscular  and 
cardiac  debility,  profound  and  rapid  blood  deterioration,  icterus, 
leucocytosis  and  melanagmia. 

The  hasmoglobinuria  must  be  differentiated  from  blackwater  fever 
proper.     The  former  complicates  a  subtertian  attack. 

It  has  been  shown  that  L.  malaria  produces  an  haemolysin  in  such 
quantities  that  it  cannot  be  kept  in  check  by  the  anti-h^molysin,  which 
results  in  dissolved  blood  being  excreted  by  the  kidneys.  Jaundice  is 
more  rare  in  this  condition  than  in  ordinary  blackwater  fever. 


MALARIA  97 

PERNICIOUS  SUBTERTIAN  FEVER. 

This  ivpe  is  caused  by  certain  viscera  being  selected  by  the  parasite 
for  sporiilation.  The  consequent  symptoms  have  local  as  well  as 
general  manifestations  owing  to  that  particular  viscus  being  affected 
not  onl\-  by  the  toxins,  but  because  of  its  impaired  nutrition,  for  the 
capillaries  may  be  completely  blocked  by  parasites,  red  cells,  swollen 
endothelial  cells,  leucocytes  loaded  with  pigment,  free  pigment  and 
merozoites.  These  fevers  are  accompanied  by  a  high  mortality. 
We  shall  now  deal  with  them  seriatim. 
(i)  Algid  Pernicious  Subtertian  Fever. 

The  condition  of  collapse  is  marked,  e.g.,  sharp  nose,  sunken 

cheeks,  lips  and  extremities  cyanotic, 
i  he  pulse  is  small,  soft,  frequent.     Respirations  are  laboured. 
The  skin  is  cold  and  clammy. 
There  is  severe  thirst. 
The  patient  may  die  in  a  few  hours. 

(2)  Diaphoretic  P.S.F. 

The  sweating  of  the  fourth  stage  is  excessive,   a  pool  of  per- 
spiration may  fall  on  the  floor  beneath  the  bed. 
Exhaustion  and  collapse  may  follow. 

(3)  Hccmorrhagic  P.S.F. 

There  may  be  haemorrhages  from  the  skin,  mucous  membrane 
of  the  bronchi,  intestines,  stomach,  or  generative  organs 
during  the  attack,  but  not  during  the  intermission. 

A  grave  anaemia  may  follow  with  :  thready  pulse,  coma,  delirium, 
convulsions  and  death. 

This  variety  is  rare. 

(4)  Scarlatinijorm  P.S.F. 

There  is  a  diffuse  scarlatiniform  rash  with  desquamation  of  the 

horny  layer  and  erythema  of  the  fauces. 
A  typhoidal  state  may  carry  off  the  patient, 

(5)  Cerebrospinal  P.S.F. 

The  symptomatic  manifestations  may  resemble  :  — 
(a)  Coma. — There  is  a  sharp  onset,  with  weakness,  sleepiness, 
headache,  disturbance  of  vision,  stupor  or  delirium, 
ending  in  coma.  The  pupils  may  be  contracted.  The 
speech  is  scanning  in  character.  There  may  be  haemor- 
rhages under  the  skin  and  into  the  retina. 

The  urine  and  motions  may  be  passed  involuntarily. 

The  heart  is  dilated,  pulse  slow,  becomes  quick  and  thready 
before  death. 

In  fatal  cases,  the  tongue  becomes  dry  and  the  patient  colder 
and  colder. 


98  DISEASES   DUE   TO    PROTOZOA 

There    may    be    improvement    for    tAventy-four    hours    with 
relapse  and  death.     Some  cases  recover. 

(b)  Hyperpyrexia. — The  temperature  may  rise  to  107° — 108°  F. 
There  may  be  brief  mania,  followed  by  muttering  delirium, 

unconsciousness,  coma  and  death  in  one  or  a  few  hours. 
It  is  due  to  embolism  by  malarial   parasites,   swollen  cells, 
debris,  &c.,  blocking  the  capillaries  supplying  the  thermic 
centre. 

(c)  Delirium. — There    may    be    delirium     with     sudden    onset, 

followed  by  exhaustion,  coma  and  death.  All  are  fatal. 
The  fever  is  usually  high.  It  may  be  mistaken  for  thermic 
fever. 

(d)  Tetanus. — Some  delirious  patients  may  show  trismus,  con- 

traction of  limbs,  opisthotonos,  retraction  of  abdomen,  and 
conjugate  deviation  of  the  eyes. 
There  may  be  recovery  or  death  with  hyperpyrexia. 

(e)  Eclampsia. — Children   may  have  convulsions,   stupor,   coma 

and  death. 

(/)  Meningitis. — It  occurs  in  young  persons  and  children.  There 
are  :  vomiting,  slow  pulse,  headache,  retraction  of  head, 
rigidity  of  neck,  convulsions,  hyperc'esthesia,  fever, 
irregular  pulse,   coma  and  death. 

(g)  Hemiplegia. — There  may  be  all  ihe  signs  and  svmptoms  of 
hemiplegia  with  paralyses.  There  may  be  aphasia,  often 
resulting  in  permanent  psychical  disturbances,  loss  of 
memory,  &c.  This  is  due  to  the  blocking  of  the  capillaries 
supplying  Broca's  convolution  (embolism). 

(h)  Amblyopia. — Blindness  is  sometimes  complained  of,  is 
usually  only  temporary  lasting  for  several  davs,  but  in 
some  cases  it  persists,  when  there  may  be  found  optic 
neuritis,  peripapillary  oedema,  extravasation  of  leucocytes, 
plugging  of  retinal  or  choroidal  vessels  bv  parasites,  pig- 
ment, leucocytes  and  consequent  multiple  haemorrhages  in 
the  fundus  (Poncet). 
In  quinine  amblyopia  (see  p.  524)  there  is  retinal  anccmia 
due  to  toxic  spasm  of  the  arterioles  and  the  amblyopia  is 
more  persistent.  The  discs  are  white  and  the  vessels 
shrunken,  while  no  inflammator}^  symptoms  are  present. 
In  the  malarial  condition  one  eye  only  mav  be  affected,  and 
the  condition  may  clear  up  quickly  under  quinine  treat- 
ment. The  pupils  react  to  light,  but  they  do  not  react  in 
quinine  amblyopia. 

(i)  Bulbar. — There  is  difficulty  of  speech  and  deglutition  with 


MALARIA  99 

facial  paralysis  or  paresis,  increased  tendon  reflexes,  ataxia 
and  vomiting. 
(y)  Cerebellar. — There    is    cerebellar    ataxia,    severe    headache, 
vomiting,  &c. 
(6)  Gastrointeslinal  P.S.F. 

The  symptoms  may  resemble — 

(a)  Cholera. — There     is     vomiting,      abdominal     pain,      severe 
diarrhoea,  the  stools  are  loose,  profuse  and  numerous,  pain- 
ful cramps  of  legs. 
Collapse   may    ensue    with    sunken   eyes,    cyanosis,    clammy 
skin,  hiccough,  severe  thirst,  scanty  urine,  delirium,  coma 
and  death. 
Occasionally  a  case  recovers. 
The  condition  may  be  mistaken  easily  for  true  cholera,  but 

the  stools  usually  contain  some  bile  (not  rice  water-like). 
The  blood  also  will  show  indications  of  malaria. 
This  manifestation  is  seen  in  the  Punjab. 


=5e 


Parasites  in  capillary  from  intestine. 

(6)  Dysentery. — The  fever  is  usually  high. 

The  stools  contain  blood  and  mucus  tinged  with  bile. 
There  is  great  distress  and  prostration. 
The  pulse  is  small  and  rapid- 
Quinine  may  result  in  rapid  recovery. 
(c)  HcEmorrhagic  Pancreatitis. 

The  diagnosis  is  made  after  death. 
It  is  seen  in  Ceylon. 

There  is  an  acute  onset  with  epigastric  pain. 
There   may   be   signs  of   partial    intestinal    obstruction    with 
marked  collapse. 
((/)  Peritonitis. — This   may   be   simulated    when    the   suprarenal 
glands  are  affected  in  particular. 
(7)   Cardiac  P.S.F. 

The  right  heart  is  enlarged,   there  is  severe  cardiac  pain,   and 
vomiting  of  blood. 


TOO 


DISEASES   DUE   TO    PROTOZOA 


The  patient  passes  into  an  algid  condition  and  dies. 

The  capillaries  of  the  heart  may  contain  blood  in  a  condition  of 
stasis  which  may  cause  the  death  of  the  patient,  especially 
in  those  with  fatty  heart  and  pericardial  adhesions. 

Chronic  alcoholic  subjects  and  beriberi  victims  run  grave  risks 
in  exposing  themselves  to  malarial  infection  (Daniels). 


'^^&&. 


«« 


« 


©^;.,^^t|V 


%  .* 


% 


Parasites  in  capillaries  of  pancreas. 

(8)  Pulmonary  P.S.F. 
Resembling — 

(a)  Pneumonia. — There  is  blood  expectoration,  in  the  red  cells 

of  which  are  seen  malarial  parasites.     There  is  dyspnoea 

and   cough.     The   symptoms   are  worse   during   the   fever 

than  during  the  remission. 
The  blood  is  usually  full  of  the  parasites. 
The  pneumococcus  complicating  the  fever  may  be  the  cause 

of  this  manifestation. 

(b)  Pleurisy. — There  is  sharp  pricking  pain,  dry  cough,  friction 

sounds,  which  are  worse  during  the  febrile  attack. 

Apart  from  all  these  varieties  of  subtertian  manifestations,  the 
testicles  may  be  selected  as  the  point  of  attack  with  the  corresponding 
symptoms.     The  appendix  may  also  be  chosen  with  its  symptoms. 

Dry  gangrene  of  the  feet  and  legs  may  be  caused,  malarial  end- 
arteritis (Tomaselli). 


MALARIA  loi 

CHRONIC  MALARIA. 

The  causative  organism  is  usually  Laverania  malari^e,  but  either 
of  the  malarial  parasites  may  cause  it. 

The  numerous  symptoms  are  often  slight  but  frequent.  There 
are  :  — 

Repeated  small  fevers,  enlargement  of  spleen  and  liver,  pigmenta- 
tion of  skin  and  mucosae,  oedema  of  feet,  anaemia  which  is  often 
marked,  haemorrhages  which  make  operations  dangerous,  multiple 
neuritis,  skin  eruptions,  sinovitis,  palpitation,  dizziness,  bronchial  and 
intestinal  disturbances,  morning  diarrhoea,  fleeting  pneumonias  and 
headaches. 

Sometimes  the  fevers  are  absent,  such  not  being  necessary  for  the 
condition. 

The  spleen  may  become  enormous  in  size,  firm  but  painless.  It  is 
very  friable,  and  may  be  ruptured  by  slight  blows  or  even  spon- 
taneously. 

Vigorous  games  and  corporal  punishment  should  be  withheld  from 
such. 

The  liver  enlarges  from  chronic  hepatitis.  There  is  hypertrophy 
of  the  intralobular  connective  tissue  which  leads  to  hypertrophic  or 
atrophic  cirrhosis.  This  incurable  condition  leads  to  portal  obstruction 
and  ascites.  The  h^emosiderin  may  be  in  blocks  as  large  as  blood 
corpuscles.     The  term  "  Siderosis  "  is  then  applied  to  this  condition. 

The  secondary  anaemia  may  be  profound  with  loss  of  red  cells,  and 
Hb.,  with  a  large  increase  of  the  mononuclear  elements. 

Abortion  and  sterility  are  common  effects  of  this  anaemia. 

The  condition  described  above  is  known  as  "  Malarial  cachexia.** 

If  the  acute  conditions  were  adequately  treated  with  quinine  this 
condition  could  hardly  arise. 

Unfortunately  malarial  relapses  are  exceedingly  common  even  when 
quinine  has  been  administered  and  without  reinfection.  Some  of  the 
parasites,  lying  dormant,  wake  up  later  and  cause  a  relapse  for  some 
unknown  reason,  unless  it  is  because  the  resistance  of  the  patient  is 
diminished  at  that  time. 

Recurrences  may  often  occur  after  several  years.  Malarial  parasites 
have  been  found  in  the  blood  four  years  after  leaving  a  malarious 
district.  Apparent  recurrences  in  malarial  districts  are  usually  re- 
infections. 

Latent  malaria  is  a  term  given  to  a  condition  when  malarial 
parasites  are  found  in  the  blood  and  there  are  no  symptoms  present. 

The  parasite  is  usually  of  the  subtertian  variety. 

Masked   malaria   is   a  term    used   when    there   may   be    neuralgias, 


102  DISEASES   DUE   TO    PROTOZOA 

cerebral  abscess,  chronic  diarrhoea,  &c.,  when  the  malarial  parasite  is 
found,  and  the  condition  clears  up  on  the  administration  of  quinine. 

Congenital  inalaria  is  doubted,  but  one  case  is  on  record  where  a 
malarial  mother  gave  birth  to  a  child,  in  the  umbilical  cord  of  which 
parasites  were  found.  After  death  they  were  also  found  in  the  heart 
blood.  The  parasites  were  identical  with  those  in  the  maternal  blood 
and  the  placenta.  Bignami  and  others  have  failed  to  find  parasites  in 
similar  cases. 

Juvenile  malaria,  when  chronic,  causes  stunted  growth  and  retarded 
puberty. 

SEQUELiE  AND  COMPLICATIONS. 

The  sequels,  such  as  neuritis,  neuralgia,  anaemia,  cirrhosis  of  the 
liver  and  of  the  spleen,  with  traumatic  rupture  of  the  same,  have 
already  been  mentioned,  but  to  these  may  be  added  mental  modi- 
fication, insanity,  tinnitus  aurium,  vertigo,  deafness,  anosmia  and  loss 
of  taste. 

Malaria  may  be  complicated  by — 

Typhoid  fever,  to  which  condition  the  term  of  typho-malaria  has 
been  applied.  There  is  no  hybrid  or  distinct  disease,  but  the  one 
complicating  the  other,  there  being  two  distinct  causative  organisms 
present. 

Amoebic  dysentery  may  be  present,  but  one  must  not  forget  that 
malaria  itself  can  cause  dysentery. 

Lobar  pneumonia  is  not  uncornmon.  The  low  form  in  chronic 
malaria  is  of  a  deadly  type.  The  possibility  of  a  malarial  pneumonia 
has  not  yet  been  decided. 

Nephritis  may  be  present  and  is  due  to  irritation  by  the  malarial 
toxins.     It  is  common  in  children  (Daniels). 

DIAGNOSIS. 

Decide  positively  and  treat  accordingly  if  :  — 

(i)  The  fever  has  a  typical  quartan  or  tertian  periodicity. 

(2)  When  malarial  parasites  are  found  in  the  blood. 

(3)  When  hasmozoin  is  found  in  mononuclear  leucocytes. 
Spleen  puncture  for  diagnosis  is  not  devoid  of  risk. 

A  quartan  or  benign  tertian  will  yield  to  quinine  within  four  days, 
but  not  necessarily  so  a  subtertian  attack. 

One  must  differentiate  malaria  from  :  — 

Typhoid  Fever,  Insolation,  Liver  Abscess,  Kala-azar,  Undulant 
Fever,  Influenza,  Yellow  Fever,  Dengue,  and  Seven-day  Fever. 

A  mononuclear  increase  in  a  differential  blood  count  is  useful,  but 
it  may  indicate  a  past  malarial  attack  or  pneumonia,  sepsis,  or  an  acute 


MALARIA 


103 


hepatitis.  The  latter  will  mask  it  by  producing  an  increase  of  other 
leucocytes.  Children  commonly  have  mononuclear  increase  without 
any  disease  (Daniels). 

PROGNOSIS. 

The  mortality  amongst  natives  is  usually  low. 

In  Europeans  resident  in  the  tropics  it  is  high,  Africa  in  particular. 

Simple  tertian  and  quartan  parasites  give  the  best  prognosis. 

Subtertian  is  always  grave;  pernicious  symptoms  deadly. 

People  unable  to  take  quinine  should  not  be  allowed  to  reside  in 
the  tropics,  e.g.,  malarial  countries. 

Complications  always  make  the  outlook  more  serious,  especially 
typhoid  fever  and  pneumonia. 

Syphilis  in  a  malarial  patient  will  not  vield  to  anti-syphilitic  treat- 
ment until  the  malaria  has  been  cleared  up. 

Ross  gives  us  the  following  interesting  figures  for  India  :  — 

The  mortality  is  5  per  1,000  living,  or  1,150,000  per  annum. 

It  is  greater  than  the  mortality  of  cholera  and  dysentery  combined. 

A  quarter  to  one-half  of  all  tropical  sickness  is  due  to  malaria. 

Malaria  tends  to  abound  in  the  most  fertile  countries,  hence  very 
malarial  countries  cannot  be  prosperous. 

TREATMENT. 

For  the  patient  to  "  fight  the  fever  "  himself  by  his  own  will-power 
is  a  marked  error  of  judgment,  and  an  unjustifiable  risk  for  the  patient 
to  take. 

The  indications  are  :  — 

(i)  To  kill  the  parasites. 

(2)  To  aid  the  excretion  of  the  toxins. 

(3)  To  relieve  the  symptoms  of  the  patient. 

Quinine  is  a  specific  if  the  right  kind  is  given  and  a  sufficient 
quantity  used.  Quinine  is  slightly  cumulative;  the  maximum  is 
eliminated  in  four  to  twelve  hours,  nearly  all  of  it  in  thirty-six  hours. 
It  can  be  recovered  from  the  urine  within  fifteen  minutes  from  its 
administration. 

The  sulphate  is  soluble  i  in  800  of  water  and  must  be  dissolved  in 
mineral  acids.  It  is  the  cheapest  kind,  but  is  not  to  be  recommended. 
In  the  early  days  of  quinine  treatment,  when  the  Chinese  patients  of 
Sir  Patrick  Manson  passed  the  quinine  given  as  the  sulphate  in  pills, 
the  pills  were  collected  by  Chinese  physicians,  washed,  and  sold  again 
to  fever  patients. 

The  hydrochloride  is  soluble  i  in  40. 

The  bisulphate  is  soluble  i  in  11. 

The  bihydrochloride  is  soluble  i   in   i. 


104  DISEASES   DUE  TO   PROTOZOA 

The  bihydrobromide  is  readily  soluble  in  water,   and   is  given  to 
those  with  deafness  or  headache  or  idiosyncrasy  towards  quinine. 
Quinine  valerianate  is  given  to  nervous  people. 
/         Quinine  ^annate  is  not  so  bitter  and   can   be  made   up  chocolate- 
coated  for  children. 
I        Euquinine  is  very  expensive.     It  is  useful  for  women  and  children. 

Solubility  and  Equivalent  Value  of  Salts  of  Quinine  (after  Manson). 

Amount  equiv- 


Name  of  salt 

rercriu 
alkaloid 

in  the  salt 

Solubility 

in  water 

a) 

eni  in  value 
one  of  quin- 

to 

sulphate 

Sulphate       

73-5  P 

er  cent. 

In 

800 

parts 

roo 

Hydrochloride 

8r« 

,, 

40 

5> 

•90 

Bihydrochloride 

72-0 

,, 

I 

n 

ro2 

Hydiobroniide 

76-6 

,, 

45 

1) 

•96 

Bihydrobromide      ... 

6o'o 

,,               . . . 

7 

5' 

"•23 

Bisulphate    ... 

591 

,, 

1  1 

n 

1-24 

Phosphate    ... 

...        76.2 

,, 

420 

)' 

•96 

Lactate          

...        78-2 

T1                                     .  .  . 

10 

)' 

•94 

Salicylate 

701 

1)                                     .  .  . 

225 

11 

1-05 

Hydrochloi  o-sulphate 

74-3 

,,                                     .  .. 

2 

)1 

■99 

Valerianate  ... 

73-0 

11                                    .  .  . 

1 10 

)) 

roi 

Arseniate 

69-4 

,,                                    ... 

slightly 

ro6 

Tannate 

20'0 

)»                                    ... 

)) 

3-67 

If  ingested  quinine,  especially  the  sulphates,  are  not  dissolved  by 
the  acid  gastric  juices  of  the  stomach  it  is  probably  not  dissolved  at 
all,  as  this  is  not  permitted  by  the  alkaline  juices  of  the  intestines. 
Such  quinine  is  then  excreted  practically  unchanged. 

In  small  doses  quinine  is  a  vascular  tonic,  but  in  large  doses  it  is 
a  cardiac  depressant. 

Most  of  it  is  oxidized  in  the  tissues.  The  kidney  excretes  it  as 
quinine  dihydroxyl. 

It  may  cause  cerebral  congestion,  manifesting  itself  as  tinnitus, 
deafness,  headaches,  &c.  It  may  cause  constriction  of  the  retinal 
arteries,  followed  by  temporary  amblvopia  or  degeneration  of  the 
retinal  ganglion  cells,  followed  by  permanent  amblyopia.  \^arious 
kinds  of  eruptions  have  been  reported  from  the  use  of  quinine. 

Ten  grains  of  quinine  bihydrobromide  contains  bromine  equal  to 
that  in  3  grains  of  pot.  brom.,  hence  if  this  quinine  is  used  prophy- 
lactically  for  long  periods  mental  depression  may  be  expected  from  the 
quinine  and  bromide. 

MODE  OF  ADMINISTRATION. 

Under  all  circumstances  it  is  best  given  after  food,  as  then  there 
is  more  gastric  juice,  the  acidity  of  which  facilitates  its  solubilitv. 

(i)  By  the  mouth. 

The  bisulphate  or  bihydrochloride  are  to  be  recommended  if  the 
expense    is    not    a    consideration.      They    can    be    taken    as    powders, 


.MALARIA  10 


:) 


solutions,  capsules,  cachets,  tabloids,  tablets,  or  pills.  They  may  be 
plain,  sugar,  or  chocolate-coated.  The  sugar-coated  ones  are  not  to 
be  recommended  unless  they  can  be  used  quickly,  as  the  sugar  hardens 
in  the  tropics  and  hinders  the  solution  of  the  drug.  In  some  cases  it 
is  useful,  as  it  can  be  given  to  patients  unknown  to  them. 

Tablets  or  tabloids  are  compact  and  most  useful  for  work  involving 
much  transport.  For  hospital  use  the  sulphate,  dissolved  in  mineral 
acids  and  flavoured,  is  cheapest.  Many  tropical  residents  take  5  grains 
daily  as  a  prophylactic,  or  15  grains  (i  grm.)    twice  weekly. 

A  regular  habit  is  to  be  encouraged. 

For  malarial  attacks,  5-10  and  even  20  grains  t.d.s.  has  been 
taken.  Darling  recommends  heroic  does;  such  were  absolutely 
necessary  in  the  writer's  experience  when  in  Colombia. 

One  should  wait  until  the  temperature  has  begun  to  fall  before 
administering  the  quinine,  except  in  chronic  cases,  because  the  head- 
ache is  increased,  and  the  quinine  cannot  kill  the  young  parasites  until 
the  red  cells  enclosing  them  are  ruptured. 

When  headaches  and  tinnitus  aurium  are  common,  pot.  brom., 
5-10  grains,  or  dilute  hydrobromic  acid  should  be  administered  with 
each  large  dose  of  quinine. 

In  old  Blackwater  cases  one  should  proceed  carefully  with  J-grain 
doses. 

If  the  fever  is  not  being  mastered,  inhalation  of  amyl  nitrite  may 
dislodge  the  parasites  from  the  capillaries  so'  that  the  quinine  can  get 
at  them. 

Children  stand  quinine  well  by  the  mouth.  They  must  have 
sufificient,  say  a  child  under  one  year,  from  J-iJ  grains  six  times  daily. 
A  child  aged  3-10  years  old  2-^  grains  six  times  daily. 

After  fever  in  adults  give  15  grains  (i  grm.)  daily  for  a  week,  then 
10  grains  for  two  weeks,  followed  by  5-10  grains  for  a  month. 

Iron  and  arsenic  should  be  given. 

In  patients  with  weak  hearts  digitalis  should  be  given. 

(2)  By  the  rectum. 

Useful  in  gastric  disturbance.  One  should  double  the  ordinary 
doses  one  would  give  by  the  mouth,  say  20-30  grains,  in  10-12  ounces 
of  water  or  warm  saline.  The  writer  when  in  extremis  received 
40  grains  at  night,  followed  by  40  grains  the  next  morning. 

This  method  is  most  useful  for  comatose  patients.  Use  a  large 
catheter  attached  to  a  glass  syringe  or  rubber  tube  with  funnel.  Give 
it  slowly. 

Continue  by  the  mouth  as  soon  as  possible. 

(3)  By  the  muscle. 

Subcutaneous  injections  should  be  abandoned.     The  writer  has  a 


io6  DISEASES   DUE   TO    PROTOZOA 

scar  resulting  from  a  subcutaneous  injection  of  quinine  the  size  of 
half-a-crown  tliat  he  will  carry  to  the  grave.  The  necrotic  ulcer 
required  four  months  to  heal. 

Intramuscular  injections  are  useful  when  there  are  gastric  disturb- 
ances and  serious  subtertian  attacks.  Painful  spots  may  remain  for 
months  at  the  point  of  each  injection.  I  have  seen  a  case  of  wrist 
drop  following  an  injection  of  quinine  in  the  upper  arm,  the  needle 
having  penetrated  the  musculo-spirial  nerve,  not  to  mention  the 
consequent  necrosis  caused  by  the  quinine  itself.  One  of  my  patients 
had  been  previously  treated  by  quinine  injections  in  both  buttocks 
(even  when  there  had  not  been  any  vomiting),  and  had  been  partially 
paralysed  in  both  legs  owing  to  permanent  damage  having  been  done 
to  both  sciatic  nerves. 

For  intramuscular  injections  the  bihvdrochloride  should  be  dissolved 
in  normal  sterile  saline  solution,  lo  grm.  of  quinine  in  lo  grm.  of 
saline,  given  i-ioth  at  a  time  (Bacelli). 

Giemsa's  formula  is  not  supposed  to  be  painful  in  administration. 


Quinine  hydrochloride 

lo  grm 

Aquas  destill 

i8      „ 

Ethylurethane 

5     ,. 

Give  aV  for  each  injection. 

Hermetically  sealed  vials  can  be  purchased  readv  for  use. 

The  gluteal  region  is  chosen  usually  for  the  injection  along  a  line 
drawn  from  the  posterior-iliac  spine  to  the  ischial  tuberosity. 

It  is  doubtful  if  intramuscular  injections  are  sufficiently  rapid  in 
their  action  for  severe  and  acute  cases.  There  is  always  some  local 
damage  done  and  absorption  would  be  slow  in  consequence,  during 
the  process  of  which  the  patient  might  die. 

(4)  In  the  vein. 

In  pernicious  cases  no  time  can  be  lost,  hence  the  intravenous 
method  has  its  uses. 

An  injection  of  ether  should  precede  that  of  the  quinine  if  the  pulse 
is  bad.  A  superficial  vein  about  the  elbow  should  be  chosen.  15  grains 
(roo  grm.)  should  be  given  at  a  time,  well  diluted  in  20  c.c.  of  saline, 
and  injected  slowly.  It  should  be  repeated  if  necessary,  but  after  the 
first  injection  there  may  be  sufficient  recovery  to  continue  quinine 
treatment  by  the  mouth. 

Quinine  should  be  given  with  care  in  pregnancy  as  it  may  cause 
abortion,  but  untreated  malarial  attacks  are  more  likely  to  produce  it. 

The  administration  of  Cjuinine  may  precipitate  an  attack  of 
haemoglobinuria.     5  grains  has  caused  this  (Sandwith). 

Fever  cases,  during  the  acute  attack,  must  have — 

Rest  in  bed,    light  diet,   blankets  for  cold  stage,    hot  bottles,    hot 


MALARIA  107 

drinks  to  acid  perspiration.  In  hot  stage,  vinegar  or  its  equivalent 
to  the  forehead ;  for  headache,  aspirin  can  be  used  but  in  severe  cases 
heart  failure  may  be  caused  by  it.  Caffeine  is  good  in  small  doses, 
2-3  grains.  In  the  sweating  stage  remove  all  blankets,  damp 
clothing  and  bedding,  then  administer  tepid  sponging,  iced  soda 
water,  &c.     For — 

Vomiting:  iced  champagne;  mustard  leaf  to  pit  of  stomach;  chloro- 
form and  morphine  mixture,  stomach  lavage. 

Hiccough  :  mustard  leaf,  codeine,  morphia. 

Cough:  codeine  and  morphia. 

Constipation :  calomel,   1-3  grains,  followed  by  saline. 

Hyperpyrexia:  cold  sponging,  cold  packing,  cold  baths,  cold 
enemata.  If  the  temperature  is  kept  within  limits  for  a  few  hours  the 
quinine  will  have  a  chance  to  act. 

Algidity:  salines  given  hypodermically,  intramuscularly,  intra- 
venouslv  or  per  rectum.  Warm  applications  to  body,  oxygen  inhala- 
tions, ether  and  strychnine. 

Hcrmorrhages :  calcium  lactate,  adrenalin,  salines. 

Big  spleen :  counter-irritants,  saline  aperients,  quinine,  iron  and 
arsenic. 

Convalescence :  Give  quinine  for  three  months,  iron  and  arsenic  for 
two  months.  If  the  attack  has  been  very  serious  send  patient  to  a 
cool  climate. 

PROPHYLAXIS. 

It  is  most  essential  that  all  the  scientific  methods  of  prophylaxis 
should  be  carried  out.  By  them  the  death-rate,  case  incidence,  illness 
and  mortality  from  complications,  as  well  as  the  disease  and  the 
expense  to  employers  of  labour,  are  enormously  decreased. 

The  work  of  Colonel  Gorgas  and  his  Sanitary  Staff  at  Panama  for 
the  abolition  of  Yellow  Fever  and  the  enormous  decrease  of  Malaria 
is  too  well  known  to  be  repeated  here.  This  work  was  made  possible 
by  the  sanitarian.  The  monev  spent  in  such  work  is  insignificant 
when  compared  with  the  work  achieved  and  the  lives  saved. 

Prophylactic  measures  against  Malaria  may  be  summarized  under 
two  heads : — 

(i)  Protection  against  mosquito  bites. 

(2)  Mosquito  reduction. 

These  will  now  be  dealt  with. 

(A)    PROTECTION  AGAINST   MOSQUITO  BITES. 

(i)  Mosquito  nets  must  be  used  invariably,  twenty-five  strands  to 
the  inch,  which  will  keep  out  the  Simulid^  also.  The  nets  should  be 
tucked  under  the  mattress  and  not  allowed  to  fall  looselv  on  the  floor. 


io8  DISEASES   DUE   TO    PROTOZOA 

It  should  be  kept  in  good  repair.  Each  net  will  last  one  year  in  travel, 
and  about  two  years  stationary.  When  the  strands  are  becoming  rotten 
the  nets  should  be  destroyed.  A  net  with  small  holes  or  not  tucked 
under  the  mattress  is  worse  than  not  having  one  at  all. 

(2)  Portable  mosquito-proof  rooms  could  be  used,  and  are  extremely 
useful  for  doing  night  work  or  reading  in  mosquito  districts.  They 
are  essential  in  some  districts  when  one  wishes  to  work  in  peace  during 
the  daytime  when  flies  are  a  pest. 

(3)  Fixed  mosquito-proof  rooms  can  be  used  which  are  more  stable 
for  permanent  residence.  Copper  gauze  wire  can  be  used  fixed  to 
timbers.  Portable  ones  on  frames  are  also  made  with  copper  wire, 
but  they  are  subject  to  much  damage  in  constant  transit. 

Some  steamers  trading  between  Liverpool  and  the  Amazon  are  now- 
screened  against  mosquitoes.  The  sea  air  may  be  injurious  to  the 
copper  gauze. 

(4)  Mosquito  proofing  of  windows  and  doors  excludes  flies,  moths, 
glare  of  the  sun,  damp  exhalation  after  heavy  tropical  showers,  and 
allows  the  breeze  to  enter  unimpeded.  Mosquito  wire  is  of  tinned 
iron,  copper  or  brass,  the  prices  being  as  two  is  to  three. 

(5)  Mosquito  proofing  of  verandahs.  This  is  more  expensive,  but 
in  selected  cases  gives  good  results.  It  obscures  light  and  seems  to 
retain  the  heat. 

(6)  Hands  and  feet  can  be  protected  by  mosquito  boots,  gloves,  &c. 

(7)  Medicine.  All  exposed  to  mosquito  bites  should  take  5  grains 
of  quinine  daily.  To  keep  off  mosquitoes  employ  eucalyptus,  petro- 
leum, camphor  bags  about  neck,  &c. 

Natives  like  the  mixture  of  "Camber-green  oil,"  with  which  they 
paint  their  bodies.  It  is  made  up  of  Citronella  oil,  i|;  Kerosene,  i  ; 
Cocoanut  oil,  2. 

(8)  Constant  movement  will  prevent  mosquitoes  from  settling  nearly 
as  frequently  as  they  otherwise  would. 

(9)  Fans  and  punkas.  These  creating  a  breeze  are  useful  in  houses 
or  on  verandahs.     They  can  be  driven  by  hand  or  electricity. 

(B)    MOSQUITO  REDUCTION. 

(i)  By  killing  adults  in  houses  with  a  small  hand  net. 
(2)  Fumigation  for  the  same  purpose.     This  method  is  much  used 
in  Italy  and  the  States.     Sulphur  is  generally  used. 

^-     Powdered  sulphur,  2  lbs.  per  1,000  cub.  feet. 
Moisten  with  methylated  spirits. 
Place  in  shallow  pan,  supported  on  brick,  in  a  large  flat  basin  of 

water  in  a  sealed  room. 
Leave  for  three  hours  after  ignited,  and  then  ventilate  room  well. 

Pyrethrum  powder  may  also  be  used,  3  lbs.  per  1,000  cub.  ft. 
Sulphur  affects  brass  work  and  steel  goods. 


MALARIA  109 

Camphor  and  carbolic  acid  can  be  used,  equal  parts,  4  ounces  dis- 
solved bv  gentle  heat,  per  1,000  cub.  ft.  Only  about  half  an  hour  is 
required. 

(3)  By  natural  enemies,  e.g.,  bats,  birds,  lizards,  dragon  flies, 
fishes  as  Girardinus  poeciloides  (millions),  tadpoles.  All  such  should 
be  bred  and  protected.     Such  means,  however,  are  not  always  best. 

1 1  mav  be  much  cheaper  and  better  to  remove  the  water  altogether 
than  to  maintain  "  natural  enemies." 

(4)  Dealing  with  the  larvae. — All  small  receptacles  for  water  should 
be  removed  or  filled  with  lime  or  given  a  surface  film  of  kerosene,  if 
such  are  used  for  table  legs  to  keep  away  ants,  &c. 

Larger  quantities  of  water  and  small  streams  can  be  covered  with 
a  thin  surface  film  of  crude  kerosene  which  does  not  permit  the  larvae 
to  reach  the  surface  for  air.  It  requires  half  an  ounce  per  square  yard 
ever}'  seven  days  to  be  effective. 

Wherever  possible  destroy  and  do  not  treat  mosquito  breeding 
places.  Small  pools  should  certainly  be  drained.  Holes  in  rocks  and 
trees  should  be  filled  with  rubble  and  cement.  Plants  which  breed 
them,  as  pineapples,  bananas,  &c.,  should  be  removed  from  near  dwell- 
ings. Culicines  breed  in  palm  trees  and  sugar  cane.  Larvicides, 
such  as  copper  sulphate,  &c.,  can  be  used  in  water,  which  rapidly  kills 
ofT  the  larvae,  but  it  becomes  poisonous  for  other  animals. 

(5)  Screening  of  breeding  places  is  sometimes  necessary,  such  as 
of  water  tubs,  wells,  cesspits,  &c.  Cattle  should  be  watered  at  certain 
parts  only  and  the  hoof  impressions  levelled. 

(6)  Drainage. — Open  channels  should  be  cut  in  the  soil  and  con- 
creted. Drains  could  be  of  stone  and  gravel.  Local  material  available 
will  help  one  to  decide.  The  subsoil  should  be  drained  by  pipes.  As 
much  as  possible  of  the  surrounding  land  should  be  suitably  cultivated. 

(7)  Trees  and  bush. — Eucalyptus  trees  are  not  worth  while.  Many 
.trees  should  not  be  allowed  to  remain  near  to  houses  as  they  attract 

and  give  out  moisture,  exclude  breeze  and  increase  heat. 

All  bush  and  undergrowth  Avithin  200  yards  of  all  villages,  houses 
and  dwellings  and  all  grass  within  this  area  above  12  inches  in  height 
should  be  cut  down.  A  mosquito  will  not  be  able  to  cross  such  a  zone 
without  destruction  by  sun  or  wind. 

(8)  Houses  should  be  built  several  feet  above  the  ground,  upon 
sites  high  and  dry,  well  away  from  coolie  lines  and  native  villages. 
Houses  should  be  lofty — of  stone,  if  possible,  or  brick — with  good  light 
and  ventilation,  which  mosquitoes  do  not  like.  Whitened  walls  are 
good.     Curtains  and  fancy  decorations  are  bad. 

As  to  the  height  of  the  site,  one  may  remember  that  the  temperature 
of  the  air  tends  to  fall  1°  F.  every  300  feet  above  sea-level.     Malaria 


no  DISEASES   DUE   TO    PROTOZOA 

tends  to  diminish  at  500 — 1,000  feet  high,  but  under  suitable  conditions 
it  may  be  found  5,000  feet  high. 

(9)  Rice  should  not  be  cultivated  within  five  miles  of  towns  in 
Italy  because  of  the  swampy  nature  of  the  ground.  In  India,  however, 
where  this  law  would  mean  famines  it  could  not  be  enforced. 

Professor  Pearson  has  worked  out  an  interesting  point  on  mosquito 
reduction.  Me  affirms  that  if  moscjuito  propagation  is  suppressed 
within  the  circular  area  of  a  mile — 

The  mosquito  density  at  the  centre  will  be  3  per  cent. 

At  a  quarter  of  a  mile  from  the  centre  18  per  cent. 

At  the  periphery  75  per  cent,  of  the  density  surrounding  that  area. 

Sir  Ronald  Ross's  work  at  Ismailia  reduced  malarial  cases  from 
1,551  in  1902  to  37  in  1905,  the  latter  being  all  relapses.  The  cost  of 
the  work  was  2 — 3  francs  per  head  of  the  population. 

Every  malarial  district  before  being  opened  up  should  be  systematic- 
ally surveyed  with  regard  to  malarial  propagation,  and  the  work 
commenced  at  once  on  given  lines. 

Celli  has  shown  us  some  interesting  figures  on  the 

Relative  Values  of  Malarial  Prophylaxis. 

Protection         Quinine  and 
Method  of  prophylaxis  None  Qjinine  alone    from  mosquito         protection 

alone  from  mosquito 

Percentage  of  infection  ...         33         ...         20         ...         2*5         ...         175 

Hence  quinine  alone  will  prevent  13  per  cent,  of  cases,  and 
Quinine  plus  mosquito  protection   will   prevent  3r25  per  cent,   of 
cases. 

FOR   NEW  INFECTIONS  ARE  REQUIRED:— 

(i)  That  an  infected  person  with  gametocytes  is  living  in  or  near 
to  the  locality. 

(2)  That    an    Anopheles,    capable    of    carrying"    such    gametocytes,. 
sucks  up  sufficient  blood  from  the  infected  person. 

(3)  That  this  mosquito  lives  for  a  week  or  more  under  suitable 
conditions. 

(4)  That  it  then  bites  a  person  non-immune  and  not  protected  by 
quinine. 

(5)  Infected  persons  and  carrying  flies  must  be  sufficientlv 
numerous.  If  there  are  many  flies  and  few  infected  persons  the 
chances  of  becoming  infected  are  greater  than  if  there  were  few  flies 
and  many  infected  persons. 

The  following  facts  may  be  of  interest  :  — 

Spleen  Rate. 

Within  300  yards  of  jungle,  undrained,  it  was  47  per  cent. 


THE   MALARIAL   MOSQUITO  iii 

Within  i,ooo  yards  it  diminished  to  2*6  per  cent.  (Watson). 

At  the  edge  it  was  59  per  cent. 

Fry  found  it  to  be  2s  per  cent,  at  200  yards  away  and  nil  at  one  mile 
distance. 

Mosquitoes  fly  readily  for  a  Cjuarter  of  a  mile,  but  half  a  mile 
appears  to  be  beyond  the  normal  distance  of  flight.  A  gentle  breeze 
will  carry  them  a  distance  of  one  and  a  half  miles. 

100,000  mosquitoes  per  100  yards  square  was  once  worked  out  to 
be  an  average  number  present. 

Anopheles  are  not  hungry  for  twelve  to  twenty-four  hours  after 
being  hatched  out  or  after  laying  eggs. 

On  an  average  only  one  out  of  forty-eight  of  all  females  ever  have 
the  chance  of  carrying  malaria  even  in  a  malarial  district  (Ross). 

The  cost  of  a  new  hospital  wOuld  often  suffice  to  prevent  more  cases 
of  sickness  than  are  treated  in  it,  and  the  cost  of  invaliding  would  often 
suffice  to  prevent  the  disease  which  caused  it. 


THE  MALARIAL  MOSOUITO. 

The  knowledge  of  these  mosquitoes  is  so  extensive  that  special 
works  must  be  consulted  for  details.  A  resume  only  of  the  outstanding 
facts  can  be  attempted  here. 

The  four  great  families  of  the  Xematocera,  order  Diptera,  which 
are  of  interest  to  the  medical  officer  are  the — 

(i)  Culicidas,  or  mosquitoes. 

(2)  Psychodidfe  or  moth-like  midges,  containing  the  notorious 
Phlebotomus. 

(3)  Chironomid^e,  or  midges. 

(4)  Simulidi^e,  all  the  species  of  which  are  extremely  bloodthirsty. 

FAMILY  CULICIDiE. 

They  are  distinguished  from  the  midge-like  flies  by  :  — 
(i)  The  venation.     The  costal  vein  runs  all  round  the  edge  of  the 

wing. 
,,     first  vein  is  very  long. 
,,     second  bifurcates. 

,,     third  is  very  short  and  goes  off  the  second 
at  right  angles. 


ij 


fourth 


both  bifurcate. 


,,     fifth 
,,     sixth  is  simple  and  short. 
(2)  The  close  fringe  of  scales  on  the  posterior  border  of  the  wings. 


112  DISEASES   DUE   TO    PROTOZOA 

(3)  The  projecliiiij;-  proboscis  of  extraordinary  length. 
There  are  two  sub-families  :    (a)  Corethrinae. 

(b)  Culicinc'e. 

SUB-FAMILY  CULICIN^. 

Genus  Anopheles. 
The  Sub-genera  are  important  :-■• 
Anopheles  (sensus  restrictu). 
Mvzorhynchus. 
Arribalzagia. 
Christ3^a. 
]\Iyzom}ia. 

Pyretophorus. 
Nyssorhvnchus. 
Neocellia. 
Cellia. 
Chagasia. 
All  known  carriers  are  included  in  the  Genus  Anopheles,  of  which 
there  are  about   100  species  universally  distributed,  but  chiefly  in  the 
Tropics.      Every    medical    ofBcer    should    examine    the    stomach    and 
salivary    glands   of    mosquitoes    caught    in    his    district    for    malarial 
parasites  in  order  to  ascertain  the  species  prevalent  there. 
For  the  dissection  of  mosquitoes,  see  p.  637. 
The  known  malarial  carriers  in  the  dififerent  countries  are  :  — 

(After  Alcock.) 

IN  EUROPE. 

Anopheles  maculipennis. 
,,  bifurcatus. 

,,  ("  Pyretophorus  ")  superpictus. 

,,  (Myzorhynchus)  pseudopictus. 

IN  SOUTHERN  ASIA. 

Anopheles  (Myzomyia)  lis'.onii. 
,,  ,,  culicifacies. 

,,  (Myzorhynchus)  barbirostris. 

,,  ,,  sinensis. 

,,  (Nyssorhynchus)  fuligiosus. 

,,  ,,  theobaldii. 

,,  ("  Neocellia  ")  stephansii. 

,,  ,,  willmorii. 

IN  TROPICAL  AFRICA. 

Anopheles  (Myzomyia)  funestus. 

,,  ("  Pyretophorus  ")  costalis. 


THE   MALARIAL   MOSQUITO  113 

Anoplieles  (Myzorhynchus)  maurilanus. 
,,  ,,  paludis. 

IN  AUSTRALIA. 

Anopheles  (Nyssorhynchus)  annulipes. 

IN  NORTH  AMERICA. 

Anopheles  maculipennis. 
,,  bifurcatus. 

IN  TROPICAL  AMERICA. 

Anopheles  (Myzomyia)  lutzii. 

,,  ("  CelHa  ")  argyrotarsus. 

•  ... 

IN  THE  UNITED  STATES  (Von  Ezdorf). 
Anopheles  allumanus. 

,,  argyrotarsus. 

,,  crucians. 

,,  intermedium. 

,,  quadrimaculatus. 

,,  pseudomaculipes. 

,,  pseudomaculipennis. 

,,  tarsimaculata. 

The   following   species   are   known    to  carry   the    larvcs   of    Filaria 
bancrofti  :  — 

Anopheles  maculipennis. 

,,  (Myzomyia)  rossii. 

,,  (Myzorhvnchus)  nigerrimus. 


,,  ,,  mmutus. 

,,  (Mvzomyia)  funes(us. 


("  Pyretophorus  ")  costalis.  '  The  Malarial  parasite  also. 
,,  {"  Cellia  ")  argyrotarsus.      ) 

SUMMARY     OF     FACTS     RELATING     TO     THE     ANOPHELES 

{ai'0)(f)6\i']s  =^  unprofitable,  harmful). 

CULICIDiE. 

Adults. — The  head  is  small,  hemispherical,  has  a  distinct  neck, 
brown  cheeks  covered  with  scales,   used  for  differentiation  of  species. 

Eyes  reniform ;  no  coelli. 

Antennae  long,  slender,  14-15  segments,  first  globose;  others  carry 
whorls  of  hairs,  wispy  in  female,  thick  and  bottle-brush-like  in  male. 

Labium,  in  the  majority,  is  long  and  slender,  covered  with  scales ; 
ends  in  pair  of  small  stiflfish  labella,  bent  when  piercing. 

Maxillary  palps,  covered  with  scales,  show  specific  and  sexual 
8 


114 


DISEASES   DUE    TO    PROTOZOA 


I,  Culicine,  male;  2,  Culicine,  female;  3,  Anopheline,  mile  ;    4,  Anopheline, ''female. 


THE   MALARIAL  MOSQUITO 


115 


differentiation;    may    be    longer    than    proboscis;    clubbed    in     male 
Anopheles. 

The  parts  ensheathed  in  proboscis  are  long,  slender,  piercing  organs 
except  in  the  Corethrin^e,  consisting  of  :  — 


Proboscis 


Antennae 

PaTpi ' 

Eyes'' 
Occiput ~" 

Protlnoracic 

lobes 
Mesothorax-""'  ^ 

Scuteilum  — 
Mcto  thorax 

orMctaootuiD 

First  abdomin'oL 
segment 

Abdomen 


Eosal 

lobes  of  Q    ..    ,  .,    , 

+    Male  genitalia 


Basal 
lobes 


Clasper. 

proboscis 

Palpi 

Antennae. 

Basal  lobes  ofantennae 

Prons 

Vertex 

Eyes 

Occiput 
Nape 


v-^^- tarsal 
ungues  ^4^ 


Diagram  showing  the  structure  of  a  typical  mosquito.     (Theobald.) 

(i)  A  Stout-pointed  epipharynx,   grooved  ventrally. 

(2)  A  slender  hypopharvnx,  which  is  itself  an  efferent  tube  for  the 
saliva;  forms  when  applied  to  the  epipharynx  a  groove  known  as  the 
afferent  suctorial  tube. 


ii6 


DISEASES   DUE    TO    PROTOZOA 


(3)  A  pair  of  slender  mandibles  expanded  and  very  finely  serrated 
at  the  tip.     (Absent  in  the  males.) 

(4)  A  similar  pair  of  maxilUe  coarsely  serrared  ar  tip.     (Absent  in 
the  males.) 

Sometimes  the  mouth  parts  of  the  males,  which  only  live  on  juices, 
appear  to  consist  solely  of  the  epipharynx  and  labium 


Photographs  of  living  mosquitoes,  C.  impellcns.  Walk.).  Above  $  and  J  in  profile ;_in 
the  middle  ventral  aspects  of  the  same;  and  beneath  J  and  J  dorsal  views.  About  twice 
natural  size. 

Thorax  is  covered  with  scales  or  hairs. 

Scutellum  is  narrow,  not  lobed  in  .Anopheles,  and  is  overlapped  by 
the  menatonum,  which  is  bare. 

Abdomen  is  long,  narrow,  scales  or  hairs,  nine  segments,  last 
bilobed,  complicated  in  the  male  with  a  pair  of  chitinous  clasping 
hooks. 

The  wings  are  as  described  above;  all  the  veins  are  clad  with  scales, 
lanceolate  in  shape  for  Anopheles. 


THE   MALARIAL  MOSQUITO 


117 


The  halteres  (balancers)  are  plainly  visible. 
The  legs  are  long,  slender;  fifth  segment  carries  pair  of  claws. 
In  order  to  spot  the  male  from  the  female  readily  use  the  antennas 
as  the  chief  guide. 


-^iSPEajStev 


8 


9 

Various  forms  of  Mosquito  Eggs. — (l)  Egg-boat  of  Ciilex,  seen  from  above;  (2)  the  same, 
side  view  (after  Sambon)  ;  (3)  separate  Cities  eggs;  (4)  eggs  of  Panoplites  (after  Daniels); 
(5)  ^gg^  "^f  Stegomyia  ;  (6)  the  same  more  highly  magnified  (after  Theobald)  ;  (7)  groups  of 
Attophales  eggs,  as  they  float  on  the  water  (after  Sambon)  ;  (8)  egg  of  Anopheles  maculipennis, 
showing  lateral  floats,  seen  from  above,  ;<  30  diams.  ;  (9)  the  same,  viewed  laterally  (after 
Nuttall). 


a,  eggs  of  Culex  ;  b^  b'^,  eggs  of  Anopheles  ;  c,  egg  of  Stegomyia  ;  d,  egg  of 
Teeniorhynchus  ;  e,  egg  of  Psorophora. 

For  the  differentiation  of  species  see  a  special  work. 
Eggs. — These  are  laid  on  the  surface  of  the  water — 
If  as  a  sheet  of  jelly-like  frog's  spawn  they  are  of  the  Corethra. 


ii8 


DISEASES  DUE   TO    PROTOZOA 


Breathing  apertures 


The  anterior  parts  are 
shown  in  the  prone  position 
and  the  hinder  ends  in  profile, 
owing  to  the  body  being 
twisted  by  the  pressure  of 
the  cover-glass. 


(Anopheles  rossii,  Giles  ;   larva) 


Breathing  tube 


(Culex  impellens,  Walker  ;    larva) 


Palpi 


Palpi 


Male 


Female 


Anooheles 


G.  M.  Giles,  de  nat.  dec. 


Male 


r 

Culex 


Femcle 


THE   MALARIAL  MOSQUITO  119 

If  in  groups  or  rafts  they  are  of  the  Culex. 

If  singly  they  are  of  the  Anopheles. 

Each  Qgg  is  oval,  one  end  blunter  than  the  other,  with  a  pigmented 
chitinous  shell.  It  has  a  very  fine  external  membrane  which  facilitates 
the  floating  of  the  eggs. 

They  hatch  in  twenty-four  hours  in  a  hot  tropical  season. 

Larvce. — All  must  live  in  water  and  can  be  found  in  collections 
almost  anywhere,  even  in  sea  water,  but  not  as  a  rule  in  rivers  where 
the  current  is  strong.  They  are  very  active,  and  live  principally  on 
algag  and  similar  vegetable  matter. 

The  head  is  a  rounded  chitinous  capsule  with  well-developed 
appendages. 

The  eyes  are  irregular  masses  of  pigment  in  the  younger,  and 
distinctly  faceted  in  the  older  ones. 

The  antennae  are  long. 

The  clypeus  is  prominent,  to  which  are  attached  the  "  mouth- 
brushes,"  which  have  a  rotatory  motion  to  sweep  food  to  the  mouth. 

The  thorax  has  three  segments,  distinguished  from  the  abdomen 
only  by  an  arrangement  of  hairs,  which  are  in  tufts,  single-branched 
or  feathered. 

The  abdomen  is  elongate,  soft,  with  nine  segments  sometimes  beset 
with  stiff  hairs  like  the  woolly-bear  caterpillar,  but  usually  hairs  are 
lateral  and  on  the  free  edge  of  the  last  segment.  On  the  dorsum  of 
the  eighth  segment  the  breathing  organs  open  by  two  independent 
orifices  in  Anopheles,  or  one  breathing  tube  of  varying  length  in  others. 
This  latter  has  a  valve  and  carries  spines. 

The  intestine  opens  at  the  free  end  of  the  ninth  segment,  which 
carries  bunches  or  whisks  of  hairs  and  four  tapering  tracheal  gills. 

In  repose  some  larvae  hang  with  the  head  downwards  with  the  tip 
of  the  breathing  tube  at  the  surface  for  air,  but  the  larva?  of  the 
Anopheles  groups  lie  horizontally  to  the  surface. 

Larvas  become  fully  grown  in  about  one  week,  but  in  cold  climates 
may  remain  unchanged  during  the  winter. 

They  moult  several  times  and  feed  continuously. 

Pupa. — They  must  live  in  water. 

They  are  active,  but  do  not  feed. 

In  appearance  thev  are  like  tiny  lobsters. 

The  head  and  thorax  form  one  mass. 

Two  ear-like  breathing  trumpets  come  from  the  back  of  the  head 
mass  for  breathing. 

The  curved  abdominal  ninth  segment  ends  in  a  pair  of  large  blade- 
like fins. 

On  the  first  segment  there  are  two  tufts  of  hairs,  fan-like,  to  catch 


120 


DISEASES   DUE    TO    PROTOZOA 


the  surface  film  and  to  bring  the  pupa  into  a  good  position  for 
breathing. 

The  pupa  matures  in  two  days  in  hot  weather. 

When  the  adult  is  about  to  emerge  the  pupa  straightens  its  back, 
the  skin  of  the  cephalothorax  bursts  along  the  back,  out  of  which 
opening  the  adult  appears.  It  rests  for  a  few  minutes  and  then  flies 
away . 


Vn^pa.  oi  Anopheles  niaculitennis,  Meig.     Enlarged.      (After  Grassi.) 


Soon  after  a  female  is  hatched  it  probablv  becomes  fertilized;  some 
maintain  that  it  takes  blood  first;  oviposition  follows  the  blood  meal, 
and  takes  place  in  the  earlv  morning. 

The  time  of  development  is  (average)  :  — 


Egg      stage 
Larval      ,, 
Pupal       ,, 


I  to 

7  „ 

•7 


i8 


days 


lo  to  24  days,  or  longer 


BIONOMICS. 

The  imago  emerges  from  the  pupa  during  the  late  afternoon  when 
the  female  is  ready  for  fertilizing  the  male.  The  latter  sex  usually 
predominates  numerically. 

The  female  alone  bites  man  and  animals  in  order  to  obtain  blood, 
which  forms  rich  food  for  the  eggs,  but  much  more  rarely  they  will 
feed  on  juices,  the  Culicinie  more  than  the  Anophelinaj. 

The  mouth  parts  of  the  female  alone  are  adapted  for  piercing. 

It  is  during  this  act  that  malarial  sporozoites  are  injected  into  the 


THE   MALARIAL   MOSQUITO  121 

human  bodv  from  the  infected  mosquitoes.  They  pass  down  the 
hypopharynx  or  salivary  tube,  while  blood  and  malarial  "gametes  pass 
up  the  labial  tube  to  the  mouth. 

They  feed  mostly  at  night,  but  may  do  so  at  any  time  of  the  day. 

Thev  become  blown  out  with  blood,  then  retire  to  digest  it. 

Next  morning  the  female  Hies  to  the  nearest  water  to  lay  her  eggs; 
she  ma_y  travel  half  a  mile  for  this  if  it  is  necessary. 

The  Anopheles  prefer  clean  water  with  weeds,  the  Culicina^  any 
kind. 

The  Anopheles  eggs  may  be  found  in  the  back-eddies  of  streams, 
margins  of  lakes,  large  wells,  puddles,  in  broken  bottles,  shells,  holes 
of  rocks  and  trees,  and  in  plants  like  bamboos,  pineapples,  &c. 

At  night  the  female  seeks  blood  again. 

The  larvffi  are  cannibals,  living  on  each  other  as  well  as  on  algse. 

These  larv^  must  be  attacked  by  the  medical  officer  everywhere, 
or  he  can  only  protect  himself  with  nets  and  drugs. 

In  the  dry  season  mosquito-larvaj  can  ^estivate  and  wait  for  more 
suitable  conditions. 

The  adult  lives  for  about  four  weeks,  not  counting  hibernating 
periods. 

One  adult  mosquito  can  give  off  200,000,000  in  four  months 
(Ficalbi). 

Adults  may  be  transported  great  distances  in  ships,  railway 
carriages,  but  it  is  by  accident  and  not  by  choice. 

The  mosquito  engorges  herself  with  blood  in  one  minute. 

She  begins  to  secrete  the  liquor  sanguinis  almost  at  once,  this  being 
the  refuse  of  digestion. 

The  peculiar  buzzing  noise  so  well  known  to  tropical  residents  is 
due  to  the  vibration  of  its  proboscis,  and  has  no  relation  to  the  wing 
movements  (Darling). 

Darling  affirms  that  Anopheline  females  will  suck  blood  at  any 
time  and  do  not  wait  for  fecundation. 

Ross  says  that  the  female  sucks  blood  after  fecundation,  also  that 
the  male  only  lives  for  a  few  days. 

Darling  says  that  the  male  lives  fifteen  to  nineteen  days,  e.g.,  as 
long  as  the  female  when  suitable  food  is  available,  such  as  sliced 
banana,  &c. 

Mosquitoes  are  not  confined  in  their  attacks  for  blood  upon  man, 
for  they  are  known  to  attack  invertebrates,  e.g.,  insects,  and  also 
young  fish. 

Possibly  a  quarter  of  the  total  number  of  anopheles  may  succeed 
in  biting  human  beings  once.  A  third  of  these  may  live  for  a  further 
ten    days,    of   which    only   a   quarter    may    succeed    in    biting    again. 


122  DISEASES   DUE    TO    PROTOZOA 

That  is,  only  one  out  of  every  forty-eight  mosquitoes  can  ever  have  a 
chance  of  carrying  malarial  parasites  (Ross). 

The  Mansoni  titillans  has  now  been  found  to  be  the  most  numerous 
of  all  mosquitoes  in  the  Panama  Canal  Zone.  It  has  habits  which 
enable  it  to  escape  both  in  the  larval  and  pupal  stage  all  larvicidal 
efforts,  as  these  stages  are  passed  beneath  the  water.  This  is  rendered 
possible  by  breathing  tubes  being  adapted  for  piercing  the  rootlets  of 
the  Pistia  stratiotes  and  thus  obtaining  their  supply  of  oxygen.  The 
roots  are  sometimes  several  feet  long,  and  to  these  the  larvas  are 
attached.  Xot  all  plants,  however,  contain  them,  other  conditions 
being  necessary. 

The  adult  mosquito  has  long  been  known  in  the  Canal  Zone,  but 
the  larvce  and  pup^e  have  not  before  been  found. 

TRYPANOSOMIASIS. 

(i)  African  Trypanosomiasis. 

(2)  South  American  Trypanosomiasis. 

(3)  Notes  on   Mammalian  Trypanosomiasis. 

AFRICAN    TRYPANOSOMIASIS. 
DEFINITION. 

An  acute  specific  infection  caused  by  :  — 

(i)  Trypanosome  gambiense,  carried  by  Glossina  palpalis. 

(2)  Trypanosome  rhodesiense,  cari-ied  by  Glossina  morsitans. 

Other  species  of  trypanosomes  may  cause  the  disease. 

The  morbid  manifestations  are  :  irregular  chronic  fever,  fleeting 
skin  eruptions,  local  oedema,  adenitis,  physical  and  mental  lethargy, 
mania,  eye  lesions,  tenderness  of  muscles  and  bones. 

HISTORY. 

The  '*  surra  "  of  India  has  been  ascribed  to  the  bites  of  certain 
blood-sucking  flies  by  the  natives  from  time  immemorial. 

1724.  John  Atkins  in  "The  Navy  Surgeon  "  described  the  sleep- 
ing distemper  common  among  the  negroes  of  the  Guinea  Coast,  seen 
by  him  in  1721,  but  not  published  until  1724. 

1803.  Winterbottom  described  it  as  he  saw  it  on  the  West  Coast 
near  Sierra  Leone.  Slave  dealers  would  not  buy  slaves  with  enlarged 
cervical  glands. 

1846.     Trypanosomes  first  found  in  fishes. 

1879.  Lewis  found  the  rat  trypanosome  (T.  lewisi)  in  Bombay. 

1880.  Evans  found  the  T.  evansi  in  horses  of  India  at  Madras. 


AFRICAN   TRYPANOSOMIASIS  123 

1849.     Clarke  saw  trypanosomiasis  on  ihe  Gold  Coast. 
1869.     Guerin  found  it  in  Martinique  in  the  negro  slaves  imported 
from  Africa. 

1890.  Nepveu  found  the  trypanosome  in  the  blood  of  man  in 
Algeria  while  searching  for  malaria.  This  was  the  first  time  it  had 
been  found  in  man,  and  it  was  accidental  (Manson).  Its  significance 
was  not  then  known. 

1891.  The  first  case  was  brought  to  London  under  Sir  Stephen 
Mackenzie. 

1895.     Bruce  showed  that  "  nagana  "  was  due  to  T.  brucei. 

1900.  Two  human  cases  were  brought  to  London  under  Sir  Patrick 
Manson.  The  morbid  anatomy  of  these  cases  was  studied  in  detail  by 
Dr.  Mott.    . 

1901.  Ford  and  Dutton  found  T.  gambiense  in  the  blood  of 
patients  on  the  Gambia. 

1902  and  3.  Castellani  found  trypanosomes  in  the  cerebrospinal 
fluid  of  patients  in  Uganda. 

1903.  Sir  David  Bruce  and  Nabarro  showed  that  Trypanosomiasis 
was  spread  by  Glossina  palpalis,  an  hypothesis  alreadv  formed  by 
Sambon  and  Brompt  on  epidemiological  grounds. 

1905.     Thomas  introduced  "  atoxyl  "  for  treatment. 

1907.  A  bureau  was  founded  in  London  for  the  studv  of  the 
disease.  Ehrlich  found  that  trypanosomes  mav  become  atoxvl- 
resistant.  Plimmer  and  Thomas  introduced  tartar  emetic  associated 
with  atoxyl  for  treatment. 

1910.  Stephens  and  Fantham  created  a  new  species,  e.g.,  T. 
rhodesiense. 

191 2.  Kinghorn  and  York  showed  that  G.  morsitans  was  a  trans- 
mitting agent  for  T.  rhodesiense.  Livingstone  (1841-1873)  gave 
arsenic  to  horses  for  nagana. 

Manson  had  used  liquor  arsenicalis. 

DISTRIBUTION. 

It  was  first  noticed  on  the  West  Coast  of  vSierra  Leone.  It  was 
imported  from  this  endemic  centre  to  the  West  Indies  from  time  to 
time,  where  it  soon  died  out. 

In  1882  it  existed  from  Senegal  to  Loando  and  the  islands  of  the 
Gulf  of  Guinea.  It  was  much  wider  spread  at  this  time,  but  it  was  not 
known  to  civilization. 

In  1898  it  was  known  on  the  Upper  Niger. 

Tlje  disease  was  probablv  spread  in  Africa  as  follows  :  — 

In  1886  vStanlev  took  some  Congolese  natives  across  Africa  to  the 
Victoria  Nile.     Some  of  these  natives  settled  to  the  west  of  Lake  Albert 


124  DISEASES   DUE    TO    PROTOZOA 

Nyanza  and  in  Uganda.  There  is  little  doubt  that  men  of  Stanley's 
expedition  and  Emin  Pasha's  followers  carried  the  disease  with  them 
across  Africa  into  Busoga  and  Uganda.  The  former  place  was  known 
to  be  infected  in  1896,  and  the  latter  extensively  infected  by  1900.  The 
western  shores  of  Victoria  Nyanza  were  found  infected  in  1901  ;  the 
eastern  shores  and  German  East -Africa  in  1902  ;  Button  and  Todd  found 
ii  widelv  disseminated  in  the  Congo  Stale  1904-1905,  spreading  along 
trade  routes.  These  writers  stated  that  the  disease  would  spread  into 
Eastern  Rhodesia,  which  has  since  come  true.  It  has  spread  upwards 
from  Uganda  to  Wadelai  on  the  Victoria  Xile  since  1904,  and  had 
invaded  the  Lado  before  1908.  It  was  recognized  in  the  Sudan, 
Bahr-el-Ghazal  province,  in  1909. 

Its  present  boundaries  (1919)  are  :  — 

On  the  West  Coast  from  St.  Louis  in  Senegal  to  Mossamedes  in 
Angola,  up  to  Timbuctoo  on  the  Niger,  throughout  the  Congo  into 
Uganda,  Rhodesia,  Southern  Nyasaland  and  Portuguese  East  Africa. 

From  Uganda  and  Busera  southwards  to  German  East  Africa  and 
Lake  Tanganyika,  and  northwards  to  the  Bahr-el-Ghazal  province. 

It  may  spread  to  Arabia  as  tsetse  flies  exist  there. 

Of  course  it  may  also  spread  to  co-existing  lands  wherever  tsetse 
flies  prevail. 

AETIOLOGY. 

The  known  causative  organisms  are  T.  gambiense,  1902,  and 
T.  rhodesiense,  1910.  The  L'^ganda  strains  may  differ  from  the  others, 
an  hypothesis  suggested  by  the  difiference  of  its  virulence. 

The  trypanosomes  of  animal  trypanosomiasis  may  cause  it.  Pro- 
fessor Lanfranchi,  who  has  never  left  Europe,  was  accidentally  infected 
with  a  supposed  laboratory  strain  of  T.  brucei,  causing  irregular  febrile 
attacks,  general  debility,  and  large  patches  of  cutaneous  tvdema  over 
a  period  of  two  years. 

T.  gambiense  probably  lives  in  antelopes  chiefly. 

T.  rhodesiense  in  hartebeest,  waterhogs  and  domestic  pigs. 

These  animals  and  man  form  the  reservoir  from  which  man  is 
infected. 

It  is  not  known  if  Glossinae  infect  their  eggs. 

Trypanosomes  are  known  to  develop  more  rapidly  at  high  tem- 
peratures. 

The  trvpanosomes  are  injected  at  the  same  time  as  the  Glossina 
palpalis  and  morsitans  suck  blood. 

Koch  has  suggested  that  it  may  be  also  transmitted  by  sexual 
intercourse. 

Some  authorities  blame  mosquitoes  also. 


AFRICAN   TRVPANOSOMIASIS 


125 


iMinchin  considers  that  encysted  forms  from  fly  dropjDings  may  be 
ingested  and  cause  infection. 

It  is  fairly  conclusive  that  Tabanides  convey  it  mechanically  from 
beast  to  beast  in  herds  of  cattle. 

Race  does  not  affect  infection. 

Occupation  predisposes  in  so  far  as  there  may  be  exposure  to  the 
flies  near  their  breeding-  places  or  cover  areas.  Hence  those  working 
along  the  shores  of  rivers  and  lakes  of  infected  regions  are  exposed  to 
the  bites  of  infected  Glossinaj,  usually  palpalis,  while  porters  marching 
through  the  bush  are  exposed  to  the  bites  of  G.  morsitans. 

THE  PARASITE. 

As  seen  in  Jrcsli  bluod  the  trypanosome  is  an  active  wriggling 
organism  with  a  laterally  compressed  spindle-shaped  body,  provided 
with  a  delicate  undulating  membrane.  Fringing  the  dorsal  edge  of 
the  trypanosome  and  terminating  in  a  free  whip-like  filament  is  the 
flagellum. 

Stained  specimens  show  a 
nucleus,  somewhat  central,  and  a 
minute  deeply  staining  chromatic 
mass,  the  blepharoplast,  which  is 
nearer  to  one  pole,  e.g.,  the 
thicker  or  aflagellum  or  anterior 
end  of  the  organism.  Near  to 
the  blepharoplast  is  a  small  non- 
staining  area,  viz.,  the  vacuole. 
The  thickened  free  border  of  the 
undulating  membrane  springs 
from  the  blepharoplast  at  one 
end,  and  is  continued  as  the 
flagellum  at  the  other. 

In  some  places  the  cytoplasm  is  homogeneous,  while  in  others  it  is 
faintly  granular  when  stained. 

There  is  great  diversion  in  the  dimensions  of  the  parasite  in  body, 
nucleus  and  flagellum. 

Multiplication  is  bv  longitudinal  division,  commencing  at  the 
blepharoplast,  which  elongates  and  then  divides.  This  is  followed  by 
the  duplication  of  the  thickened  margin  of  the  undulating  membrane 
and  longitudinal  division  of  the  whole  body.  The  flagellum  does  not 
divide. 

The    complete    separation    of    the    two    halves   along    the   posterior 
border  does  not  take  place  until  the  new  flagellum  has  been  formed. 
When  separation  takes  place  it  is  postero-anteriorly. 
Sexual  differences  have  not  been  decided  upon. 


Trypanosoma  gaiiibiense. 
(After  Dutton.) 


1,700. 


126  DISEASES   DUE    TO    PROTOZOA 

HABITAT. 

Parasites  occur  in  the  blood,  lymphatic  glands,  cerebrospinal  fluid 
and  probably  in  the  fluid  of  the  serous  cavities,  which  facts  point  to 
the  lymphatic  system  as  being  the  most  important  habitat. 

It  may  be  very  difificult  to  find  the  parasites  in  the  peripheral  blood. 
When  present  they  may  be  more  readily  found  during  a  febrile  attack. 

T.  gambiense  has  not  yet  been  cultivated  on  artificial  media,  but 
it  can  be  readily  communicated  to  monkeys,  dogs,  rats,  guinea-pigs 
and  other  animals. 

The  rat  trypanosome,  T.  lewisi,  has  been  cultivated  through  many 
generations. 

During  adverse  conditions,  such  as  increasing  scarcity  of  nutri- 
ment, lowering  of  temperature,  addition  of  chemical  solutions  and  the 
influx  of  sera  from  non-susceptible  animals,  the  trypanosomes  tend  to 
agglutinate,  e.g.,  to  congregate  in  bunches,  with  their  extremities 
(anterior)  directed  towards  the  centre. 

One  bunch  may  contain  loo  individuals.  The  parasites  mav 
disperse  again,  apparently  unaltered  and  uninjured. 

In  cultures,  trypanosomes  may  assume  a  spherical  form  and  lose 
their  flagellum. 

The  time  required  for  the  trypanosome  to  remain  in  the  fly  before 
transmitting  the  infection  is  probably  20 — 47  days  (Manson). 

CLASSIFICATION. 

(After  Bruce,   Lectures  before  Royal  College  of  Physicians,    1915.) 
Classification  is  based  upon  :  — 
(i)  Morphology. 

(2)  Pathogenic  action  of  animals.       ^ 

(3)  Mode  of  development  in  tsetse  flies. 
Cultivation  is  of  no  assistance  at  present. 

Inoculation  experiments  and  serum  diagnosis  are  not  helpful  for 
diagnosis  on  the  field. 

(i)  Morphology. 

In  fresh  films  one  ascertains  the  general  appearance  of  the  trvpano- 
somes  and  the  kind  of  movement.  Some  vibrate  about  one  spot, 
others  hurl  themselves  about  the  field  with  great  power  and  velocity. 

Stained  specimens  give  more  exact  details  as  to  length,  breadth, 
cell  contents,  nucleus,  micronucleus,  undulating  membranes  and 
flagellum. 

(2)  Pathogenic  action  on  animals. 

The  passage  of  a  trypanosome  through  a  series  of  animals  of  the 
same  species  exalts  their  virulence  towards  that  animal,  e.g.,  the  wild 
strain  of  the  nagana  trypanosome  which  kills  a  rat  in  20 — 30  days,  but 


AFRICAN   TRYPANOSOMIASIS  127 

if  passed  through  rats  for  many  generations  the  rat  will  be  killed  by 
them  in  two  days. 

The  passage  of  trypanosomes  through  dififerent  species  will  lower 
their  virulence,  e.g.,  some  wild  trypanosomes  will  kill  monkeys  in  a 
few  days,  but  if  passed  first  through  a  goat,  an  attempt  to  infect  the 
monkey  fails,  hence  its  passage  through  the  goat  lowers  die  virulence 
of  trypanosomes  for  monkeys. 

Care  is  necessary  in  adopting  this  as  a  means  of  differentiation. 

It  has  been  observed  that — 

T.  brucei  is  more  virulent  for  laboratory  animals  than  T.  gam- 
biense.  Some  are  deadly  to  horses  and  cattle,  and  are  harmless  to 
dogs,  monkeys  and  rabbits.  Others  show  a  preference  for  domestic 
pigs. 

(3)  Mode  of  Development  in  Tsetse  Flies. 

All  the  trypanosomes  pathogenic  to  man  and  domestic  animals  in 
Africa,  with  the  exception  of  two  northern  species,  pass  through  a 
specific  cycle  of  development  in  the  tsetse  flies.  The  mode  of  develop- 
ment in  the  tsetse  is  different  for  different  species,  and  this  feature  may 
be  used  for  differentiation.  North  African  species  have  not  been  found 
capable  of  developing  in  tsetse.  It  may  be  that  from  disuse  they  have 
lost  the  faculty,  if  ever  they  had  it. 

CENTRAL   AFRICAN   PATHOGENIC   TRYPANOSOMES. 

Group  (A):  Trypanosome  Brucei  Group. 

Synonyms  :  T.  rhodesiense,  T.  ugand^e.  The  question  of  identity 
of  T.  rhodesiense  and  T.  brucei  is  still  sub  judice. 

The  differentiation  of  the  groups  is  according  to  the  development 
of  the  trypanosome  in  the  tsetse.  The  microscope  will  decide  to  which 
group  the  trypanosomes  will  belong. 

General  features  of  all  in  this  group. 

All  are  more  or  less  polymorphic. 

They  vary  much  in  size  and  shape. 

The  cytoplasm  contains  numerous  dark-staining  granules. 

The  kinetonucleus  is  small  and  situated  at  some  distance  from  the 
posterior  extremity. 

The  undulating  membrane  is  well   developed  and  has  bold  folds. 

They  affect  many  species  of  animals,  including  man,  cattle,  horses, 
dogs,  &c. 

T.  brucei  and  T.  gambiense  develop  in  the  tsetse  in  the  same  wa}-, 
at  first  in  the  intestine,  then  in  the  salivary  glands.  There  they  com- 
pletely develop  into  infective  forms.  No  other  group  invades  the 
salivary  glands. 

(i)  Trypanosoma  brucei. 


128  DISEASES   DUE    TO    I'KOTOZOA 

U  is  ihe  must  widely  disl-ribuled  pathogenic  irypanosome  of 
Central  Africa. 

It  causes  nagana  amongst  domestic  animals. 

In  Nyasaland  it  causes  trypanosomiasis  in  man. 

It  is  rapidly  fatal  to  man  and  domestic  animals. 

It  is  carried  by  the  Glossinae  morsitans  and  pallidiijes. 

(2)  T.  gambiense. 
Synonym  :   T.  nigeriense. 

It  causes  trypanosomiasis  in  man. 

Cattle  and  antelopes  form  the  reservoir  for  the  virus  without  causing 
symptoms  in  them. 

This  trypanosome  is  less  fatal  to  man  than  T.  rhodesiense.  vSome 
recover. 

It  is  carried  by  the  G.  palpalis. 

(3)  T.  evansi. 
Synonym  :  T.  soudanense. 

It  causes  surra  in  horses  and  mules,  camels  and  cattle  in  India, 
Philippines,  Mauritius,  North  Africa,  &c. 

It  is  transmitted  by  the  bites  of  fleas,  flies  and  ( ?)  b\-  eating  infected 
meat. 

(4)  r.  equiperdum. 

It  causes  dourine  or  mal  de  coit  in  horses  in  Europe,  India,  Xorth 
America  and  North  Africa. 

It  is  spread  by  coitus. 

It  is  always  fatal  from  two  to  eighteen  months. 

Group  (B):  Trypanosoma  Pecorum   Group. 

General  features  of  all  in  this  group  : — 

All  are  small  and  monomorphic. 

The  cytoplasm  is  non-granular. 

The  kinetonucleus  is  prominent,  sub-terminal,  and  often  seems  to 
project  beyond  the  margin. 

The  undulating  membrane  is  fairly  well  developed. 

Development  begins  in  the  intestine,  and  later  passes  to  the 
proboscis  and  salivary  duct  or  hypopharynx,  where  they  complete  their 
development  and  beco)ue  infective. 

(i)  T.  pecorum. 

Synonyms  :   T.  confusum,  T.  nanum. 

It  causes  an  important  trypanosomiasis  in  cattle. 

It  is  carried  bv  T.  morsitans,  in  which  its  development  takes  place. 

It  is  also  carried  mechanically  by  Tabanidfe  (?). 

(2)  T.  simice. 

Synonym  :  T.  ignotum. 

It  rapidly  kills  domestic  pigs. 


AFRICAN   TRYPANOSOMIASIS 


129 


Its  flagellum  is  uncertain. 

Its  reservoir  is  the  warthog". 

Group  (C):  Trypanosoma  Vivax  Group. 

General  features  of  all  in   this  group: — 

They  are  monomorphic. 

Their  movements  are  extremely  rapid. 

Their  posterior  extremity  is  enlarged. 

The  cytoplasm  is  clear  and  hyaline. 

The  kinetonucleus  is  large  and  terminal. 

The  undulating  membrane  is  but  little  developed  and  simple. 

The  trypanosome  only  affects  horses,  cattle,  goats  and  sheep. 

It  does  not  affect  dogs,  rabbits  and  pigs. 

Development  begins  in  the  labial  cavity  of  the  proboscis,  later  in 
the  salivary  duct  or  hypopharynx.  No  part  takes  place  in  the  intestinal 
tract. 


Trypanosoma  bmcei  in  division,     n,  nucleus  ;  bl,  blepbaroplast ;  /,  flagellum.      x  2,000. 

(After  Laveran  and  Mesnil.) 


(i)  T.  vivax. 

Synonym  :   T.  cazalboui. 

It  is  very  active. 

It  is  widely  distributed. 

It  attacks  horses,  cattle,  sheep  and  goats  only. 

It  is  fatal  to  cattle  in  Uganda. 

(2)  T.  caprce. 

It  affects  cattle,  sheep  and  goats  only. 

It  is  more  heavily  built  than  the  above. 

It  is  found  in  Nyasaland  and  L.  Tanganyika  only. 

(3)  T.  uniforme. 

It  is  as  T.  vivax,  but  smaller. 
It  is  only  found  in  Uganda. 

9 


130  DISEASES   DUE    TO    PROTOZOA 

These  trypanosomes  will  now  be  dealt  with  a  little  more  in  detail. 
T.  hrucci  (rhodesiense). 

History. 

It  causes  nai^^ana  in  domestic  animals. 

It  causes  Trypanosomiasis  in  man  of  a  virulent  type. 

It  was  the  first  pathogenic  trypanosome  discovered  in  Central'  or 
South  .Africa.  Jl  was  found  by  Sir  David  Bruce  in  North  Zululand, 
1895. 

Stephens,  in  1909,  was  examining  a  supposed  gambiense  at  Liver- 
pool when  he  noticed  different  characters  to  those  expected,  hence  he 
called  it  T.  rhodesiense.  The  parasite  was  obtained  from  a  patient 
who  had  been  resident  in  Northern  Rhodesia  and  was  suffering  from 
Trypanosomiasis.  In  this  way  the  Congo  and  the  Rhodesian  types 
of  the  disease  were  differentiated  for  the  first  time. 

It  lias  been  decided  for  the  present  that  T.  brucei  and  T.  rhodesiense 
are  identical. 

Distribution. 

T.  brucei  and  nagana  are  widely  distributed  from  the  Sudan  on 
the  north  to  Zululand  on  the  south,  from  Gambia  on  the  west  to 
Zanzibar  on  the  east.  It  may  be  that  the  T.  togolense  of  Togoland 
and  the  T.  ugandas  of  Uganda  are  the  same  species. 

Morphology. 

In  the  T.  brucei  there  is  a  greater  diversity  of  shape  than  is  found 
among  species  of  other  groups;  the  short,  stumpy  forms  have  no  free 
flagellum,  while  the  long  forms  are  slender  and  have  a  well-marked 
free  flagellum. 

They  are  actively  motile,  but  do  not  move  far  from  one  place. 

The  protoplasm  of  many  trypanosomes  show  granules,  especially 
at  the  anterior  end. 

The  nucleus  is  oval  in  the  slender  and  round  in  the  stumpy  forms. 
It  is  frequently  placed  far  back  in  (he  bod\'  of  the  organism,  more  so 
in  the  short  forms. 

The  kinetonucleus  is  small,  round,  and  about  1*4 — 2  ^  from  the 
posterior  extremity. 

The  flagellum  averages  5"8  jj,,  bul  is  absent  in  stinnpy  forms. 

Animal  Susceptibility . 

It  attacks  man,  horses,  mules,  donkeys,  oxen,  goats,  sheep, 
monkeys  and  dogs.  Birds,  crocodiles,  lizards  and  frogs  are  not 
affected  by  it. 

One  trypanosome  may  begin  the  infection  as  well  as  a  thousand. 

Infection  can  take  place  very  easily  through  the  skin;  the  slightest 
puncture  or  scratch  suffices.  Infection  probably  takes  place  also 
through  the  mucous  membrane,  l^ndoubtedh'  infection  is  most 
frequently  by  the  tsetse  bite. 


AFRICAN   TRYPANOSOMIASIS  131 

The  disease  runs  a  fairly  rapid  course  in  man,  killing  him  in  three 
to  four  months.  Horses,  donkeys  and  mules  die  in  about  thirty-eight 
days. 

In  the  ox  it  is  more  chronic  and  some  recover. 

It  is  fatal  to  horses  as  in  man.  No  case  infected  has  been  known 
to  recoA^er,  and  remain  free  from  the  disease  for  a  year. 

Goats,  sheep,  monkeys,  dogs,  rabbits,  guinea-pigs  and  rats  nearly 
all  die.     Amongst  these  animals,  three  recovered  out  of  318  infected. 

It  is  highly  probable  that  the  Trypanosome  of  man  in  Nyasaland 
and  of  nagana  are  not  separate  species. 

Carriers. 

Glossina  morsitans  and  pallidipes  are  the  carriers  of  nagana. 

About  one  per  500  of  tsetses  are  infected  with  the  trypanosome. 

The  infected  tsetses  are  equally  numerous  all  the  year  round. 

If  man  is  bitten  bv  one  tsetse  in  the  nagana  area  it  is  500  to  i 
against  his  taking  the  disease. 

For  its  development  in  the  tsetse  see  the  development  of  T.  gam- 
biense,  which  is  identical  with  T.  brucei  in  this  respect. 

Reservoir. 

The  big  game  of  the  fly  country  are  very  heavily  infected,  more 
than  ;^2  per  cent.     These  form  the  reservoir. 

The  other  trypanosome  species  pathogenic  to  domestic  animals 
were  found  as  follows  :  T.  pecorum,  i4"4  per  cent.;  T.  simiae,  I'y  per 
cent.;  T.  capra),  iri  per  cent,  of  all  the  game  examined.  Conse- 
quently all  such  game  should  be  exterminated  (Bruce)  in  those  areas. 

T.  gambiense. 

History. 

It  was  first  seen  in  the  blood  of  man  in  1901. 

It  was  found  by  Dr.  Ford  and  described  by  Dr.  Dutton,  but  it  was 
not  then  associated  with  Trypanosomiasis. 

The  next  year  Dutton  and  Todd  were  sent  out  to  investigate  the 
trypanosome  at  Bathurst.  They  reported  that  in  their  opinion  the 
blacks  were  immune  to  the  disease,  but  that  they  acted  as  reservoirs 
for  the  more  susceptible  whites. 

The  real  danger  was  ascertained  by  the  Royal  Society  Commission 
in  Uganda,   1903. 

Distribution . 

North. — From  St.  Louis,  at  the  mouth  of  the  River  Senegal,  to  the 
Bahr-el-Ghazal  district  in  the  Egyptian  Soudan. 

East. — Down  to  the  eastern  shore  of  Victoria  Nyanza. 

South.- — To  the  southern  end  of  Lake  Tanganyika,  the  River 
Luapula  in  Northern  Rhodesia,  and  Donguela  in  Portuguese  West 
Africa. 


J.;}2 


DISEASES  DUE   TO    PROTOZOA 


Morphology. 

It  much  resembles  the  nagana  parasite. 

There  is  great  variation  between  the  long  and  short  forms,  but 
among  the  short  forms  there  is  an  absence  of  the  blunt-ended  ones. 

The  protoplasm  contains  many  chromatin  granules. 

There  are  no  posterior  nuclear  forms. 

The  kineto  nucleus  is  small,  round,  from  r8 — I'l  ^  from  the 
posterior  extremity. 

The  undulating  membrane  is  well  developed  and  has  bold  folds. 

The  tlagellum  is  long  and  free,  except  in  the  short  forms,  where  it 
is  absent. 

The  length  of  the  organism  is  about  the  same  as  the  T.  brucei. 

No  difference  can  be  ascertained  by  the  microscope  in  blood  pre- 
parations between  T.  gambiense  and  T.  brucei. 


3 
f 


.'^ 


Trypanosoma  gambiense.  Development  in  vertebrate  host,  a,  long,  slender,  /',  intermediate 
and  c,  short,  stumpy  forms,  found  in  the  blood  :  d,  e,  /,  non-flagellate,  latent  forms  from  internal 
organs,      x  2,000.     (Original.     From  preparations  by  Fantham.) 

Animal  Siisccpiibility. 

Tt  is  difficult  to  infect  experimental  animals  from  infected  human 
blood,  and  in  this  it  differs  much  from  T.  brucei. 

The  rat  is  the  least  refractory,  but  its  virulence  can  be  increased 
by  passing  it  through  several  of  the  same  species. 

The  virulence  of  both  these  trypanosomes  is  illustrated  by  the  table 
below  :  — 


Monkey 

Dog 

Guinea-pig 

White  rat 

T.  gambiense 

159 

96 

264 

137 

T.  brucei 

26 

34 

67 

30 

hence  T.  gambiense  is  much   more  chronic  than   T.  brucei,   and  this 
test  is  best  for  the  differentiation  of  the  species. 


AFRICAN   TRYPANOSOMIASIS  133 

Carriers. 

The  Glossina  palpalis.  It  inhabits  wooded  shores  of  rivers  and 
lakes. 

Although  the  shores  of  Lake  Victoria  Nyanza,  the  banks  of  the 
Nile  and  other  rivers  swarmed  with  these  tsetses  before  1898,  they  only 
became  infected  with  trypanosomes  about  this  time.  Consequently 
one  concludes  that  the  infection  was  brought  by  Emir  Pasha's  men 
from  the  Belgian  Congo. 

Thirty  per  cent,  of  the  natives  working  for  the  Government  (one 
month  yearly,  at  Entebbe  in  Ugand^  in  lieu  of  hut  tax)  were  infected 
with  these  trypanosomes  in  1903.  The  hut-tax  labourers  were  removed 
from  the  lake  shores,  and  one  year  later  the  flies  infected  with  this 
parasite  fell  from  11 '2  per  1,000  to  i'2  per  1,000. 

In  191 2,  as  the  lake  shores  became  more  deserted,  it  had  fallen  to 
o'i4  per  1,000.     Hence  man  in  the  A'icinity  means  more  flies  infected. 
A  fly  may  remain  infective  for  several  months. 
Man  is  bv  no  means  the  only  source  of  the  virus. 
Tsetses  can  convey  the  infection  for  some  fifty  days  after  the  fly 
has  fed  on  an  infected  animal  (Kleine). 

An  infected  flv  mav  and  does  infect  susceptible  creatures  bitten  on 
the  first  bite. 

Cycle  of  Development. 

The  cvcle  of  development  of  the  T.  gambiense  in  the  G.  palpalis 
is  as  follows  :  — 

Laboratory  flies  when  fed  on  infected  animals  become  infective  in 
an  average  of  thirty-six  days,  extremes  twenty-seven  to  fifty-three  days. 
Of  those  tsetses  allowed  to  feed  on  infective  animals,  only  o'5o  per 
cent,  become  infective. 

When  in  test-tubes  the  trypanosomes  seem  to  die  off,  but  after 
twenty  davs  a  resistant  strain  appears  which  soon  multiplies  by 
myriads. 

Manv  flies  become  infected,  but  few  become  infective,  e.g.,  try- 
panosomes partially  develop  in  many,  but  go  on  to  completion  in  but 
few  tsetses.  It  was  found  that  2  per  cent,  became  infected,  but  only 
o"5  per  cent,  infective. 

For  the  first  three  to  four  days  after  the  Glossina^  have  fed  on 
infected  blood,  trypanosomes  are  found  in  all,  these  being  the  try- 
panosomes originally  ingested  with  the  blood.  In  six  to  seven  days, 
when  digestion  is  completed,  most  have  disappeared  from  the  tsetse, 
except  in  from  2  per  cent,  to  8  per  cent,  of  those  infected.  In  the 
remainder,  say  about  5  per  cent.,  the  trypanosomes  develop,  increase, 
and  fill  the  whole  of  the  gut,  fore,  mid  and  hind  gut,  with  swarms  of 
multiplication  forms. 


134  DISEASES   DUE    TO    PROTOZOA 

This  infection  may  continue  for  the  rest  of  the  life  of  the  fly. 

One  case  retained  its  infection  for  ninety-six  days,  but  some  lose 
their  infectivitv  and  become  harmless. 

Trypanosomes  are  never  found  in  the  proboscis  except  immediately 
after  a  meal. 

The  greatest  development  is  found  in  the  fore,  mid  and  hind  gut, 
first  degenerate  blood  forms,  then  comes  a  dominant  type,  a  long, 
broad  form  with  a  narrow,  simple,  undulating  membrane  and  a 
very  short  flagellum,  if  one  at  all.  This  appears  to  rise  from  a  pink- 
coloured  body  near  the  kineto  nucleus,  a  condition  or  phase  never  seen 
in  ordinary  blood  trypanosomes.  There  are  masses  of  these  at  all 
times  in  all  parts  of  the  gut.  When  the  blood  supply  runs  low  these 
degenerate  and  disappear.  When  there  is  fresh  blood  supply  they 
multiply  and  increase  at  an  astounding  rate,  hence  there  are  at  the 
same  time  trypanosomes  in  all  phases  of  their  development  which 
beggars  description. 

Trypanosomes  appear  in  the  salivary  glands  on  the  twenty-fifth 
day  and  remain  present  there.  They  arrive  there  b}'  way  of  the 
proboscis  and  salivary  duct  or  hypopharynx.  Trypanosomes  have 
never  been  found  in  the  body  cavity.  As  soon  as  the  trypanosomes 
reach  the  salivary  gland  they  revert  to  the  original  blood  forms  and 
become  infective. 

Conclusions. 

Trypanosomes  taken  into  the  alimentary  canal  of  tsetse  flies  retain 
their  shape  and  infectivitv  for  some  eighteen  hours. 

They  then  degenerate  and  lose  their  power  of  infectivity. 

Thev  disappear  in  the  majority  of  cases  within  five  to  six  days. 

In  a  small  percentage  of  flies,  the  female  and  the  male,  the  try- 
panosomes retain  their  position,  multiply,  swarm  in  the  gut,  but  do 
not  resemble  the  original  trypanosomes. 

After  some  twenty  days  the  trypanosomes  reach  the  salivary  gland, 
resume  their  original  blood  form,  and  regain  their  infectivity. 

Reservoir. 

When  men  were  numerous  about  the  shores  of  Lake  Victoria 
Nyanza,  20  per  cent,  to  50  per  cent,  of  the  natives  were  infected.  (The 
epidemic  there  has  since  died  out.)  Months  after  the  natives  had  been 
removed  the  flies  were  still  infective.  Animals  were  then  suspected 
and  examined.  Cattle  were  found  heavily  infected,  but  showed  no 
sign  of  the  disease,  but  healthv  susceptible  animals  could  be  infected 
from  them  by  tsetses.  The  same  can  be  said  of  antelopes.  Animals 
not  showing  the  trypanosomes  microscopically  would  infect  susceptible 
animals.  Five  years  after  the  removal  of  the  population  from  about 
certain  parts  of  the  shores  of  Lake  Xvanza  antelopes  were  still  carrying 


AFRICAN   TRYPANOSOMIASIS  135 

infective  trypanosomes.     Should  tliis  district  become  repopulated  the 
epidemic  undoubtedly  would  come  back  again. 

Groups  (B)  and  (C). 

None  of  these  attacks  man,  hence  little  will  be  said  about  them. 

Group  (B). 
T.  pecorum. 

Morphology. 

It  causes  the  most  important  trypanosome  disease  of  domestic 
animals  in  Central  Africa. 

It  is  the  smallest  of  all  pathogenic  trypanosomes,  being  9 — 18  /a 
long.     It  is  short  and  stout. 

The  contents  of  the  cell  are  homogeneous. 

The  nucleus  is  oval  and  centrally  placed. 

The  kineto  nucleus  is  small,  round,  situated  towards  the  posterior 
extremity,  and  may  appear  to  project  beneath  the  edge  of  the  organism. 

The  undulating  membrane  is  simple.     There  is  no  free  f^agellum. 

Pathogenicity. 

It  is  a  disease  of  herds,  horses,  donkeys,  oxen,  goats,  sheep  and 
pigs.     Some  attacked  recover. 

It  readily  loses  its  virulence  by  passage  through  certain  other 
animals.  If  a  trypanosome,  infective  to  the  monkey  or  dog,  &c., 
passes  through  a  goat,  it  loses  its  power  of  infectivity  for  the  monkey 
and  dog,  &c. 

T.  nanum  is  really  a  strain  of  T.  pecorum. 

It  is  not  so  rapidly  fatal  to  horses,  donkeys  and  mules. 

In  Nyasaland  two-thirds  of  the  cattle  were  lost  and  seven-eighths 
of  the  goats. 

Carriers. 

The  Glossina  morsitans.     The  Tabanidae. 

4'6  per  1,000  tsetses  were  infected  by  the  T.  pecorum. 

Once  a  herd  is  infected,  then  ordinarv  cattle  or  buffalo  flies — the 
Tabanidae,  may  spread  it.  These  flies  come  and  go  in  swarms,  during 
which  visits  they  are  real  pests  to  cattle. 

The  cattle  feed  at  the  hottest  time  of  the  day  and  crowd  for  self- 
protection,  hence  conditions  are  very  favourable  for  mechanical  trans- 
mission. When  diseased  members  of  a  herd  are  removed,  the  disease 
seems  to  cease  when  the  Tabanidae  and  not  the  Glossina  morsitans  are 
present. 

Between  1908-1913  some  2,500  to  3,000  head  of  cattle  died  in  the 
Barotse  Reserve  in  Northern  Rhodesia,  though  no  Glossina  morsitans 
was  present. 

The  mortality  begins  in  February  and  ceases  in  June  each  year. 


136  DISEASES   DUE    TO    PROTOZOA 

Development. 

At  first  this  takes  place  in  the  gut  of  the  tsetse,  then  in  the  labial 
cavity  of  the  proboscis,  later  in  the  salivary  duct,  but,  be  it  noted,  not 
in  the  salivary  gland.  In  the  salivary  duct  it  reverts  to  its  original 
form  and  becomes  infective. 

The  cycle  requires  nineteen  to  fifty-three  days  for  the  development 
of  infectivity.  The  intestinal  forms  cannot  be  distinguished  from  other 
intestinal  developmental  forms  of  pathogenic  trypanosomes. 

Thousands  of  infective  forms  can  be  obtained  by  a  biting  fly 
attempting  to  bite  one's  finger  through  a  watch  glass,  when  the  saliva 
will  reveal  them. 

Reservoir. 

I4'4  per  cent,  of  animals  examined  were  infected.     These  were  :  — 

Eland,  60  per  cent. ;  Koodoo,  66  per  cent. ;  Bush  buck,  70  per  cent. ; 
Bufifalo,  22  per  cent. 

T.  brucei  were  not  found  in  any  of  the  animals  examined. 

T.  simian. 

This  is  very  virulent  towards  monkeys  and  domestic  pigs,  killing 
them  in  a  few  days.  It  is  harmless  to  oxen,  antelopes,  dogs  and 
smaller  experimental  animals.     It  affects  goats  and  sheep. 

It  is  like  T.  pecorum,  in  that  its  virulence  soon  becomes  modified. 

The  warthog  is  the  onlv  member  of  wild  game  yet  found  to  harbour 
it.     10  per  cent,  of  the  thirtv  examined  were  found  to  be  infected. 

The  trypanosome  is  14-24  jit  long. 

The  long  undulating  body  frequently  extends  in  a  straight  line. 

The  cytoplasm  is  clear. 

It  is  very  fatal  to  domestic  pigs,  killing  them  off  in  5'3  days. 

It  kills  monkeys  in  io*8  days,  goats  and  sheep  in  46*6  days. 

3'4  per  1,000  flies  were  infective  after  experiments. 
Its  development  in  the  tsetse  is  as  that  of  T.  pecorum. 

Group  (C). 

The  size  only  separates  the  species  of  this  group. 

T.  vivax. 

It  causes  the  most  important  cattle  disease  in  Uganda. 

It  is  widely  distributed  in  Central  Africa.  It  has  been  reported 
from  the  Soudan,  Senegal  and  Northern  Rhodesia. 

Its  marked  activity  during  life  distinguishes  it. 

It  only  affects  horses,  cattle,  goats  and  sheep.  Other  animals  are 
refractory. 

It  has  been  found  in  the  bush  buck. 

Tsetse  flies  were  found  infected  by  it. 

T.  uniforme. 

As  above,  but  smaller. 


ESSENTIALS   OF   TROPICAL   MEDICINE. 
PLATES  A  TO  E  FROM  REPORTS  OF  SLEEPING  SICKNESS  COMMISSION. 

Plate  A. 


Mott. 


<D 


Q 


Figs.  1-4. 
Appearances  presented  by 
the  vessels  of  the  brain  in  a 
very  chronic  case  of  sleeping 
sickness. 


.0  ^.-,* 


Q 


Fig.  2. 
Small  vessel,  with 
plasma  cells  (/)  and  large 
granule  cells,  which  I 
have  termed  morular  cells 
(;«).  They  correspond  to 
Kornchen  Zellen  of 
Alzheimer.  Magnifica- 
tion 500. 


S 


P 


TJion. 


.1 


Fig.  I. 
Transection  of  small 
vessel  of  medulla  oblon- 
gata, showing  perivas- 
cular infiltration  with 
hyaline  lymphocytes.  In 
the  centre  of  the  blood 
vessel  is  a  trypanosome 
(i).  Amidst  the  blood 
corpuscles  there  are 
numerous  small  and  large 
mononuclear  leucocytes 
ijuon.  /.).  Magnification 
500. 


V. 


•••v.'.-'- 

•  V**  ••'■  ."^   ** 

•••••      •  .1   ;    » 


TTL 


Fig.  3. 
Small  vessel  dividing 
into  two  capillaries,  show- 
ing nuclear  proliferation 
of  the  endothelial  cells  ; 
in  the  neighbourhood  are 
plasma  cells  (/),  lym- 
phocytes (/),  and  glia 
cells  (g).  Magnification 
500. 


li 


Q 


<£> 


o  '^9 


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Fig.  4. 
Section  of  spinal  gan- 
glion,  showing    lympho- 
cyte   interstitial   infiltra- 
tion  (/).      Magnification 


A.Kelley  del 


Bale  gLDamelsson.L'^^  hih. 


Platk  B. 


Mott. 


Fig.    I. 
Three   large   glia  cells  (,!?),    their   branches  ending   in  a  network  around   and   upon  a  small   vessel: 
lymphocytes  (/),  and  plasma  cells  (/>)  are  seen  scattered  about.     Magnification  500. 

Fig.   2. 
Small  vessel,  showing  endothelial  nuclei  proliferated,  and  three  plasma  cells.     Magnification  500. 


o 


m 


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QCL 


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t) 


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Fig.  3. 

A  transection  of  a  vessel 
in  a  very  chronic  case  of 
sleeping  sickness,  show- 
ing marked  perivascular 
infiltration.  Magnifica- 
tion 250, 


'«& 


v.. 


(^ 


I  ^ 


o 

<9 


^<E> 


'H'. 


l_ 


% 


<^k 


Fig.  4. 
(^  J  Active  prolifer- 

^-^   /  ating  young  glia 

f  cells    found      in 

great  numbers  in 
sleeping  sickness 
tissues.  The 
pale  nucleus,  with  distinct  nuclear 
membrane,  contains  chromatin 
granules,  with  an  arrangement  in- 
dicating mitosis.  Surrounding  the 
nucleus  is  the  pink-stained  cyto- 
plasm, with  a  tendency  to  form  star- 
like processes.     Magnification  500. 


^sartfiP^^^^"*-" 


r\ 


^:) 


-^^ 


»f 


5. 

Fig.   5. 
Two  large  morular  cells  from  a  very  chronic  case  of  sleeping  sickness.     Magnification  500. 

Fig.  6. 

Rod  cells  (Stabchen  Zellen)  are  rarely  met  with,  although  occasionally  appearances  like  fig.  6  are  seen. 


Magnification  500. 
A  KeDey  del 


Bde  3tDanieissoD,L'^''-lLth 


Plate  C. 


Fig.  I. 


TraiLsection  of  cervical  nerve  close  to  the  spinal  ganglion,  showing  an  infection  of  the  sheath  of  the 
nerve  by  diplo-streptococci.  The  adjacent  lymphatic  glands  showed  points  of  suppuration.  Magnifi- 
cation 200.     (a)  The  micro-organisms,  magnified  500.     Case  69,  L.  L. 


1 


•  tf  •*>?*?<>* 


.(■•"rK-i-fJi.  »^ 


.  <''  it-.  • 


la. 


•'•vv*--'-.^.; 


Fig. 


V^essel  of  the  internal  capsule  of  a 
case  of  acute  sleeping  sickness,  with  a 
large  plug  of  cocci.  Magnification 
.Stained  by  Gram's  method. 


50a 


li  5)a..C«1 


^' 


%  '^^ 


N 


Fig.  3. 
Various   degenerated    cells 
seen     in     section     of    sterile 
lymphatic    gland.      Magnifi- 
cation 1,000.   Leishman  stain. 


O/ 


,fr». 


1*?     '-m^     ®      si) 

6 


4i. 


f 


Fig.  4. 
Lymphocytes  and  their  transition  to  plisma  cells  a,  c  ;  d,  degenerated  plasma  ceil 
seen  in  section  of  lymphatic  gland.     Magnification  1,000.     Leishman  stain. 


A   Kelley   del. 


Bale  &.DainelsEOu..1-,*-^llth 


Mott. 


Plate  D. 


Fig.  I. 
Thread  -  like 
bodies  and  gran- 
u  1  e  s  deeply 
stained,  seen  in 
section  of  lym- 
phatic gland, 
probably  altered 
and  degenerated 
trypanosomes. 
Magnification 
1 ,000. 


Fig.  2. 
Trypanosome    in    a     lymphatic     gland 
section  amidst  disintegrated  cell  products. 
Figs.  3  and  4  (Plate  IV.),  and  figs,  i  and  2 
(Plate   v.),  are  drawings  made  from   the 
same    sections,  5  M  in  thickness,    stained 
with  Leishman's  stain  and  prepared  from 
an  enlarged  cervical  gland  removed  during 
life    from   a    case    (Bara 
Risgallah)    of    trypano- 
some fever,  before   sym- 
ptoms of  sleeping  sickness 
had  occurred.     Magnifi- 
cation 1,000. 


Fig.  3. 
'Trypanosoma 
Gainbiense  i  n 
,  smear  of  fresh 
gland  juice, 
several  1  y  m- 
phocytes,  micro- 
nuclei.  Magnifi- 
cation 1,000. 


Fig.  4. 
Section  of 
lymphatic  gland 
from  a  recently 
fatal  case  of 
sleeping  sickness 
in  a  European. 
The  glands  in 
tliis  case  were 
not  much  en- 
larged. There  is 
a  very  marked 
proliferation  of 
the  endothelial 
nuclei.  Magnifi- 
cation 500. 


Fig.  s. 
Proliferation  of  the  connective  tissue  cells  of  the 
reticulum  of  a  lymph  sinus;  marked  proliferation 
of  the  nuclei  of  the  endothelial  cells  seen.  This 
chronic  change  closely  accords  with  the  change 
observed  in  the  perivascular  lymph  spaces  of  the 
central  nervous  system.     Magnification  500. 

Fig.  6. 
Various  granules  and  products  of  cell  (and  try- 
panosome ?)  degeneration  seen  in  the  perivascular 
infiltration    of   the    central     nervous     system     in 
sleeping  sickness.     Magnification  1,000. 


A.Kelley-  del. 


Baie  &.Daai«l»soa,  J>^  lith 


Plate  E, 


Molt.  Fig.  I. 

Longitudinal  section  of  vess?'  rf  brain  of  ox  that  died  of  Jinga  infection.  Trypanosonies  in  various  modified 
shapes  are  seen.  Some  of  these  may  be  amcjeboid  forms  of  trypanosomes  ;  probably  some  are  trypanosomes  which 
have  been  attaclced  by  leucocytes.     Magnification  500.     Stained  in  bulk — methylene  blue  and  eosine. 

Fig.  2. 
Small  vessel  of  the  medulla  oblongata  of  rabbit  inoculated  with  Surra.     The  animal  died   three  months  after 
infection.     Shows  a  plasmodial  mass  in  the  centre  and  trypanosomes  in  a  whorl   near  by.     Magnification  i,oo<j. 
Polychrome. 


"..  V 


^..^' 


B 


r 


r^ 


I). 


Fig.  3. 
Nerve  cells  of  above, 
showing  chromotalysis, 
and  a  small  vessel  with 
the  trypanosomes  (/) 
coiled  up,  blocking  it. 
Magnification  1,000. 
Polychrome. 


(S 


'^O 


<^<-\ 


^>- 


t.  Fig.  4. 

Somewhat  similar  appearances  as  in  fig.  2,  seen  in  longitudinal  section  of  vessel.  Numbers  of  chromatin  rings, 
probably  macro-nuclei  (A) ;  (B)  capillary  blocked  by  trypanosomes;  (C)  trypanosomes  in  the  tissue;  (D)  ganglion 
cell,  showing  marked  chromolytic  changes,  probably  due  to  capillary  obstruction.  The  nucleus  is  swollen  and  clear, 
the  body  of  the  cell  shrivelled,  and  there  is  an  absence  of  Nissl  granules.     Magnification  i  ,000.     Romanowsky. 


A  Kf'Uey  del 


Bale  8;I)faiiels60ii,L'^  litV 


AFRICAN   TRYPANOSOMIASIS  iZ7 

It  is  only  found  in  I'^anda. 

It  is  carried  by  Glossina  palpalis. 

Its  reservoir  is  in  wild  oj-ame  near  the  lake  shore. 

T.  caprce. 

It  has  onlv  been  reported  from  Lake  Tanganyika  and  Xyasaland. 

It  only  affects  cattle,  sheep  and  goats. 

It  is  very  active  during  life,  and  measures  18-32  fx  long. 

It  is  more  heavily  built  than  the  vivax ;  its  posterior  half  is  swollen 
and  the  end  blunt.  The  anterior  end  is  narrow  and  pointed.  The 
cytoplasm  is  clear.     The  nucleus  is  centrally  placed. 

The    kinetonucleus    is    large,    round,    and    close    to    the    posterior 

extremity. 

The  undulating  membrane  is  better  developed  than  in  the  T.  vivax, 
and  has  bolder  folds  and  a  well-marked  free  flagellum. 

It  kills  goats  in  56-5  days,  sheep  in  115  days,  and  rats  in  2  days. 

The  carrier  is  Glossina  morsitans. 

3'5  per  cent,  per  1,000  flies  examined  were  infected. 

Its  development  is  limited  to  the  proboscis  of  the  tsetse  fly. 

Its  reservoir  is  the  water  buck,  reed  buck,  in  per  cent,  of  which 
M^ere  infected. 

PATHOLOGY. 

The  outstanding  feature  is  a  chronic  inflammation  of  the  lymph 
system,  probably  caused  by  toxins  of  trypanosomes.  Trypanosomes 
enter  the  lymph-stream,  blood-stream,  and  the  cerebrospinal  fluid. 

There  is  polyadenitis. 

The  heart  and  other  organs  show  lymphatic  infiltration. 

There  is  fever  in  the  early  stage,  followed  by  meningo-encephalitis 
and  meningo-myelitis,  proliferation  of  neuroglia,  and  lymphocytic 
accumulations  around  the  vessels. 

These  two  processes  compress  the  vessels  and  lessen  the  blood 
supplv  to  the  brain  and  cord,  which  is  followed  by  malnutrition, 
cerebral  changes,  and  the  sleeping  sickness  manifestations. 

The  trypanosomes  cannot  pass  through   the  placenta. 

An  ultimate  secondary  infection  by  streptococci  and  pneumococci 
is  common. 

MACROSCOPIC. 

There  is  usually  emaciation,  but  the  writer  has  lost  many  who  have 
been  particularly  fat. 

There  may  be  dry  desquamation  of  the  skin  to  exfoliation.  One  of 
my  cases  was  called  ''the  serpent"  because  she  shed  her  skin  from 
time  to  time. 

There  is  polyadenitis  in  the  neck,  groins  and  all  lymphatic  glands. 


138  DISEASES   DUE    TO    PROTOZOA 

The  cerebrospinal  fluid  is  increased.  The  base  of  the  brain  is  pale, 
the  dura  mater  sometimes  adherent  to  the  bone,  the  gyri  of  the  brain 
may  be  flattened.  The  pia  arachnoid  is  thickened  in  places,  some- 
times adherent  to  the  brain. 

The  brain  substance  is  sometimes  firmer  than  usual,  but  may  be  soft 
and  edematous. 

There  is  usually  congestion  of  the  brain.  The  ventricular  fluid  is 
increased. 

The  findings  of  the  cord  are  similar.  Sometimes  there  are  haemor- 
rhages also. 

The  Cauda  equina  may  be  surrounded  by  gelatinous  tissue. 

Sometimes  there  is  ascites  and  pericardial  fluid  in  excess. 

The  lungs  may  show  pneumonic  changes. 

MICROSCOPIC. 

Mott  did  not  find  it  easy  tc  differentiate  true  trypanosome  findings 
from  those  due  to  terminal  affections  caused  by  diplococci,  streptococci 
and  colon  bacilli,  but  the  following  were  generally  agreed  upon  :  — 

Cerebrospinal  system. 

A  round-celled  infiltration  surrounding  the  vessels  of  the  pia 
arachnoid  of  the  brain  and  cord,  best  seen  in  the  membranes  where 
there  is  excess  of  cerebrospinal  fluid,  and  in  the  brain  around  the 
vessels  of  the  medulla,  pons,  cerebellum,  and  those  entering  the  base. 

There  is  a  growth  in  size,  and  then  a  proliferation  of  the  neuroglia 
elements. 

Round  cells  are  found  later  in  the  meshes  of  this  proliferated  glia, 
which  are  :  — 

(i)  Lymphocytes. 

(2)  Plasma  cells  of  JMarschalko,  having  a  nucleus  at  one  end  of  the 
cell,  probably  derived  from  lymphocytes. 

(3)  Morula  cells  of  Mott,  large,  round  or  oval  cells  with  an  eccentric 
blue  nucleus,  probably  degenerate  cells  of  IMarschalko. 

(4)  Some  mononuclear  leucocytes. 

(5)  A  few  polymorphonuclear  leucocytes. 

The  lymphocytes  are  probably  produced  by  proliferation  of  endo- 
thelial cells  about  the  perivascular  lymphatic  space. 

The  ependyma  of  the  lateral  ventricles  may  show  proliferation  and 
dense  fibrous  formation. 

There  is  atrophy  of  the  dendrons  and  diminution  of  the  Nissl 
bodies,  and  alteration  of  the  nucleus,  which  becomes  large,  clear  and 
eccentric.  The  changes  are  more  marked  in  the  cerebral  cortex  and 
medulla  than  in  the  cord. 

The  cells  of  the  posterior  spinal  ganglion  show  chromatolysis. 


AFRICAN   TRYPANOSOMIASIS  139 

The  central  canal  of  the  cord  may  be  dilated,  but  more  often  il  is 
occluded  by  cell  proliferation. 

Sometimes  there  is  haemorrhage  of  the  cord  vessels. 

These  changes  were  not  noted  in  a  cured  Tr\^pan()somiasis  case 
which  died  later  from  another  disease. 

The  lymphatic  fj^latuls. 

Trypanosomes  are  often  found  in  them. 

The  lymphatic  cells  often  change  into  cells  of  Marschalko.  These 
then  change  into  morula  cells. 

Endothelial  cells  of  a  lymphatic  sinus  proliferate,  become  phago- 
cytic, containing  lymphocytes,  red  cells  and  chromatin  particles. 

The  gland  is  congested. 

The  fibrous  tissue  of  the  capsule  and  septa  proliferate  and  become 
thickened. 

When  the  inflammation  subsides,  the  gland  tissue  becomes  less 
vascular,  firm,  hard  and  full  of  dense  fibrous  tissue. 

Secondary  infection  may  occur  and  abscesses  result. 

The  lungs. 

These  are  hyperaemic  often. 

They  may  show  pneumonic  compiicalions. 

The  heart. 

There  is  small-celled  infiltration  in  all  its  la\ers. 

Sometimes  it  shows  haemorrhages. 

The  liver  and  spleen. 

There  is  a  thickening  of  the  capsule. 

The  spleen  is  congested  and  the  trabecular  thickened. 

The  bone  marrow. 

It  is  very  cellular,  vessels  congested,  hcTmorrhages. 

SYMPTOMATOLOGY. 

There  are  three  stages  : — - 
(i)  Incubation. 

(2)  Febrile  or  glandular. 

(3)  Cerebral. 

In  all  three  the  clinical  manifestations  are  irregular  in  degree  and 
duration. 

INCUBATION. 

The  time  in  man  is  not  known.  Probably  two  to  three  weeks,  or  it 
may  be  less  than  ten  days.  Some  individuals  have  not  shown  any 
symptoms  after  being  infected  for  five  years.  I  had  several  patients 
who  had  carried  trvpanosomes  for  two  vears  and  shn\\'ed  no  other 
manifestations  of  the  disease  at  <-ill. 


140 


DISEASES   DUE    TO    PROTOZOA 


The  local  irritation  of  the  tsetse  bite  may  be  so  slight  as  not  to  be 
observed,  but  in  some  there  is  a  raised  itching  patch  which  may  last 
for  several  days. 

SUMMARY  OF  SYMPTOMS. 

To  aid  the  memory  these  may  be  summarized  as  follows  :  Poly- 
adenitis, fever,  erytiiema,  paresis,  tachycardia,  somnolence,  cedema, 
enlarged  spleen,  anaemia,  headache,  epileptiform  fits,  tremors, 
change  of  character,  itching,  hypera^sthesia,  incontinence  of  f^ces 
and  urine,  enlarged  liver,  eye  symptoms,  delusions,  insomnia, 
vomiting,  melancholia,  epistaxis,  feet  pains,  paresis  of  lower  ex- 
tremities, dermatographia,  painful  swelling  of  ankle,  sexual  impotence, 
hemiplegia,  giddiness,  deafness,  loss  of  hair,  phlebitis,  facial  paralysis 
and  orchitis. 

FEBRILE  OR  GLANDULAR  STAGE. 

This  stage  is  known  to  some  as  the  Trypanosome  Fever  Stage. 

The  manifestations  in  Europeans  are  much  more  frequent  than  in 
natives,  and  may  be  considered  as  follows  :  — 

Fever. — There  are  attacks  of  fever  unaffected  by  quinine,  lasting 
for  about  one  week  and  recurring  at  intervals,  or  the  fever  may  not 
recur,  or  may  be  so  slight  as  not  to  be  noticed,  or  it  may  be  taken  as 
a  "  touch  of  malaria." 


Chart  I,  1909,     Onset  of  disease  and  marked  temporary  effect  of  soamin  in  the 

second  week. 

The  pulse-rate  and  respirations  are  increased.  The  pulse-rate  may 
be  very  rapid  during  the  febrile  attacks  and  during  the  apyrexial  period 
also.     The  spleen  and  liver  enlarge,  but  it  is  difficult  to  exclude  malaria. 

Neuralgic  pains  and  headaches  are  common. 

Erythematous  Eruptions. — Pinkish  patches,  irregular  in  position 
and  outline  clear  in  the  centre,  mav  be  horseshoe  shape  or  circular; 


AFRICAN  TRYPANOSOMIASIS 


141 


DATE 

f/orS  1    /O 

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Chart  II,  1909.     Third  and  fifth  weeks.     Imperfect  control  of  temperature  by  soamin  and 

atoxyl  in  large  doses. 


DATE 

Feb  9 

10 

// 

/2 

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Chart  III,  1910.     Two  other  periods  some  three  months  later,  showing  absence  of  any  marked 
beneficial  effect  from  these  drugs.     Trypanosomes  were  usually  to  be  found. 


DATE 

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Chart  IV,  1910.  Marked  temporary  effect  of  intravenous  injections  of  tartar  emetic.  The 
trypanosomes,  which  before  the  injection  were  3  to  200  leucocytes,  were  not  found  for  three  days, 
but  became  as  numerous  as  before  in  six  days.  The  severity  of  the  reaction  is  indicated  by  the 
temperature. 


142  DISEASES   DUE    TO    PROTOZOA 

they  may  appear  anywhere,  but  are  usually  on  the  trunk  or  thighs. 
There  may  be  solid  intiltrated  patches  and  rubeloid  spots. 

A  mottled  and  bluish  appearance  of  ihe  trunk  is  very  important. 
When  once  seen  it  is  never  forgotten,  and  could  be  seldom  mistaken. 

Rarely  a  vesiculo-papular  eruption  is  seen. 

There  may  be  patches  of  painful  local  oedema  about  the  hands  or 
feet  readily  mistaken  for  rheumatism.  Many  of  these  eruptions  last 
for  a  few  days  and  reappear  elsewhere.    They  are  known  as  Trypanides. 

LYMPHATIC  GLANDS. 

Enlarged,  especially  in  the  neck,  posterior  triangle;  this  is  Winter- 
bottom's  sign.  They  are  soft  at  first,  elastic,  and  later  become  hard 
and  fibrous.  They  vary  in  size  from  a  split  pea  to  an  almond.  Few 
become  larger  than  this. 

Deep  Hypercesthesia. — This  is  known  as  Kerandel's  sign  from  a 
physician  who  contracted  the  disease  and  described  the  condition.  It 
is  general,  and  the  pain  on  contact  is  intense.  The  slightest  pressure 
feels  like  a  bruise  and  is  exceedingly  painful. 

A  puncture  with  an  hypodermic  needle  feels  like  a  "  red-hot  poker  " 
in  bad  cases.  An  accidental  knock  by  a  walking  stick  gives  ex- 
cruciating pain.  There  is  deep  bone  pain  as  distinct  from  deep  muscle 
pain.  It  is  felt  over  the  ribs,  extremities,  about  the  eyeballs,  face  and 
head,  so  that  wearing  a  helmet  is  painful.  The  leg  pains  have  been 
mistaken  for  beriberi. 

Localised  Oedema. — One  ankle  may  swell  for  a  time  and  then  the 
swelling  may  disapj^ear.  There  may  be  (edematous  patches  over  the 
temple  region  or  on  the  thigh.     T>ater  there  is  a  more  extensive  oedema. 

Asthenia  and  Ancemia. — The  anaemia  may  be  marked  and  ]3ro- 
gressive.  Weakness  is  considerable,  although  no  wasting  may  be 
present. 

Eye  Lesions. — Dr.  Daniels  has  called  attention  to  these,  and 
describes  them  as  toxic  irido-cyclitis,  conjunctivitis,  iritis,  keratitis, 
retinal  changes,  photophobia  and  deep  oedema  of  the  lower  eyelids, 
with  deep  ]5ain  of  the  eyeball.     Thev  were  lareh'  j^resenl  in  my  cases. 

Orchitis  is  present  in  some  cases. 

This  febrile  stage  may  go  on  for  Aears  or  it  may  be  cured,  either 
spontaneously  or  by  treatment  or  both,  except  in   Rhodesian  cases. 

The  appetite  is  usual! \-  good.  Wasting  is  absent  until  the  sleeping 
sickness  stage. 

The  symptoms  vary  mucli  in  different  individuals,  no  one  showmg 
all  of  them  except  in  very  few  instances.  A  few  of  m\'  European  cases 
chosen  at  random  will  indicate  this  point. 

Case    (i). — In    tr^panosome    area    for    eight    vears    without    leave 


AFRICAN   TRYPANOSOMIASIS  143 

(Central  Africa).  Fever  almost  constantly  for  months  past,  did  not 
take  quinine,  marked  anaemia,  weakness  marked,  pallor,  spleen  nearly 
reached  iliac  crest,  liver  slightly  enlarged,  malaria  also  present,  pains 
in  legs  and  calves  excruciating,  worse  at  night,  exhausted  because  no 
sleep,  aspirin,  bromides,  trional,  opiates  useless.  Sent  to  me  as  beri- 
beri. No  trypanosomes  in  blood,  no  auto-agglutination,  no  eruptions, 
no  eye  lesions,  pains  in  legs,  with  polyadenitis  chief  symptoms.  Sent 
home  and  diagnosis  confirmed. 

Case  (2). — In  trypanosome  area,  Central  Africa,  three  years;  some 
fever,  probably  malarial,  trypanosomes  found  in  blood,  some  auto- 
agglutination,  polyadenitis,  no  other  disease  present,  strong  man  at 
work  and  refused  treatment,  as  no  symptoms  when  first  diagnosed. 
Given  soamin  intramuscularly  and  sent  home. 

Case  (3). — History  exactly  as  above.  A  very  stout,  strong  man. 
Given  tartar  emetic  intravenously  and  Fowler's  solution  by  the  mouth, 
and  sent  to  Europe.  Dr.  Daniels  writes  some  months  later  that  he 
does  not  find  any  symptoms  of  the  disease  in  him. 

Case  (4). — In  trypanosome  area  six  months.  Central  Africa ;  an 
ideal  man,  physically  and  mentally,  prior  to  attack;  marked  weakness, 
stubborn  fever  would  not  yield  to  quinine,  frequent  micturition  for  six 
months,  sleeplessness,  nervous  prostration  marked,  admitted  to  hospital 
unconscious  the  day  after  the  fever  commenced.  Temperature  remained 
up  for  five  days,  in  spite  of  quinine  30  grains  daily,  no  malarial 
parasites  in  blood,  no  trypanosomes  found  after  forty-two  examinations, 
no  auto-agglutination,  polyadenitis  marked.  Long  convalescence, 
prolonged  weakness,  memory  poor,  headaches,  marked  mottling  of 
chest,  back  and  thighs,  purple  colour,  disappeared  on  pressure,  deep 
pains  of  legs  and  muscles  excruciating,  then  over  body,  face,  head, 
agonizing  pain  on  the  slightest  touch.  Erythematous  patches,  fleet- 
ing, red,  not  raised,  massage  impossible,  worse  at  night,  as  if  "  some- 
one was  twisting  his  legs  off  at  the  ankle,"  opiates  of  little  use. 

All  the  typical  symptoms  were  present,  except  trvpanosomes,  auto- 
agglutination  and  eye  lesions. 

Was  given  Tartar  emetic  intravenously;  ditto  Galyl ;  Soamin  bv  the 
mouth  and  intramuscularly.  Temperature  normal  for  ensuing  eight 
months;  when  discharged  all  symptoms  disappeared  except  slight  leg 
pains. 

Natives  may  show  some  of  these  symptoms,  but  in  my  cases  (over 
4,000)  there  were  no  eye  lesions,  except  oedema  and  one  persistent 
double  conjunctivitis  not  otherwise  accounted  for. 

Deep  pain  is  very  rare,  fever  also,  but  a  dry,  scalv  eruption  is  fairly 
common.  Headaches,  delusions,  hysteria  and  mania  are  common. 
Qidema  of  all  parts  common.     Trypanosomes  rare  and  aulo-aggutina- 


144 


DISEASES   DUE    TO    PROTOZOA 


tion  very  common  in  fresh  blood  films.     There  is  often  tremor  of  the 
tongue  and  fingers. 

They  decline  treatment  as  a  rule  in  this  stage  because  treatment  is 
more  painful  than  the  disease. 


'fe^ 


Child  with  trypanosomiasis  showing  cedematous  swellings  of  the  eyelids. 


THE  CEREBRAL  STAGE. 

In  the  Sleeping  Sickness  stage  death  is  inevitable,  but  when  the 
former  stage  ends  and  this  one  begins  is  not  accurately  known. 

This  stage  lasts  from  a  few  weeks  in  acute  cases  to  a  few  months 
in  chronic  cases.  Some  have  lived  for  jears,  and  have  then  died  from 
some  intercurrent  disease. 

One  notices  a  change  in  the  habits  of  the  jjatients,  the  disposition 
is  modified  more  often  for  the  worse,  they  become  apathetic,  dull,  there 
is  disinclination  for  exertion,  they  become  careless,  dirty,  find  it  difficult 
to  walk,  become  indifferent  to  most  things,  and  forget  to  masticate  the 
food  that  lies  in  their  mouths. 

Sleep  is  often  excessive,  but  it  is  more  frequently  a  lethargic  con- 
dition thai  is  manifested.  There  are  fine  tremors  of  the  tongue,  hands, 
arms,  legs,  and  even  of  the  abdomen.  There  is  a  peculiar  gait,  a 
difficultv  in  raising  the  feet  from  the  ground,  he  shuffles  along  or 
throws  his  feel  outwards  in  walking. 

There  is  no  jDaralysis  as  a  rule;  the  superficial  reflexes  are  normal, 
the  deep  reflexes  are  increased  and  then  lost.  Delusions  and  mania 
are    fairly    coiumon.      Romberg's    sign    is    sometimes    present.     Later 


AFRICAN   TRYPANOSOMIASIS  145 

there  may  be  rigidity  of  the  neck  and  legs,  a  tendency  to  permanent 
flexure  of  the  legs,  on  the  thighs,  and  abdomen.  One  case  of  mine 
could  not  bend  his  legs  at  all,  and  danced  with  them  quite  stiff  all  day 
and  night,  except  when  he  was  put  down  prostrate  by  attendants.  He 
could  not  rise  again  himself,  but  he  continued  to  dance  when  he  was 
put  in  the  upright  position. 

Hypercesthesia  is  not  common.  They  often  wound  themselves 
against  sticks,  &c. ;  ulcers  form  which  are  difficult  to  heal  owing  to 
their  reduced  condition  and  their  dirty  habits. 

Daily  fever  is  common  when  there  are  pneumonic  symptoms,  at 
night  up  to  ioo°-i04°  F.,  falling  to  subnormal  in  the  morning. 

There  may  not  be  any  fever  at  all,  or  the  temperature  may  be  sub- 
normal. There  are  no  rigors  or  sweating  in  fever  cases,  but  the  pulse 
is  unusually  quick,  90-140,  and  is  out  of  all  proportion  to  the  tem- 
perature. It  is,  as  a  rule,  regular,  readily  compressible,  and  small. 
Respirations  are  increased.  There  may  be  Cheyne-Stokes  breathing 
before  death.  Congestion  and  oedema  of  the  lungs  with  pneumonic 
patches  are  common  before  death. 

Digestion  is  good.  Sometimes  there  is  constipation,  but  more 
often  diarrhoea.  Unclean  feeding  may  account  for  it,  e.g.,  fungi, 
baked  clay,  &c.     The  usual  intestinal  flora  can  be  found. 

The  blood  shows  trypanosomes,  auto-agglutination,  mononucleosis, 
and  sometimes  polyleucocytosis  before  death. 

The  acidity  of  the  blood  is  said  to  be  increased,  or  probably  better, 
the  alkalinity  is  diminished,  which  is  probably  due  to  amino  acids 
secreted  by  trypanosomes,  and  produced  by  the  action  of  the  amino 
acids  upon  serum  proteids. 

Sexual  desire  does  not  necessarily  cease,  neither  does  menstruation, 
but  they  may  disappear  in  some  cases. 

The  lymphatic  glands  become  fibrosed,  smaller  and  harder. 

The  skin  is  usually  dry  and  rough,  but  may  be  normal. 

Emaciation  is  common,  but  not  the  rule.  Muscular  weakness  is 
very  marked,  tremors  are  pronounced,  saliva  dribbles  from  the  mouth, 
urine  and  faeces  are  passed  involuntarily,  bedsores  form,  the  pulse 
cannot  be  felt  at  the  wrist,  the  temperature  is  subnormal,  coma,  and 
death . 

Perverted  appetite  is  common  ;  they  will  sometimes  eat  earth  when 
good  food  is  at  their  side.  One  case  died  from  intestinal  obstruction, 
and  2I  pounds  of  clay  lumps  were  found  in  the  intestines.  Many  of 
the  people,  however,  are  earth  eaters  when  in  normal  health. 

Theft  is  a  common  propensity,  but  it  is  certainly  more  marked  when 
this  disease  is  present. 

Mania  is  common.     One  case  was  of  a  boy  who  attempted  to  drown 
10 


146  DISEASES   DUE    TO    PROTOZOA 

himself.  He  was  very  fat,  but  he  slept  twenty-two  hours  out  of  twenty- 
four.  He  recov'ered  under  treatment,  so  that  he  slept  but  ten  hours 
daily  and  went  to  work  again.  Some  cases  are  very  violent,  and  it  is 
impossible  to  inject  them  intravenously. 

GEdema  of  the  eyelids,  face,  legs,  arms,  penis,  scrotum  and 
abdominal  w-all  is  fairly  common  in  the  final  stages.  Ascites  may  also 
supervene,  also  an  increase  of  the  pericardial  fluid. 

Irido-cyclitis  and  other  eye  troubles  were  so  rare  in  my  cases  as  to 
be  ignorable.  My  district  was  4,800  sq.  miles  in  extent,  wdth  a 
population  of  from  100,000 — 200,000,  of  whom  75  per  cent,  were 
infected  with  the  disease. 

Some  cases  die  from  the  disease  without  any  enlargement  of  the 
lymphatic  glands,  and  others  survive  w'hen  they  have  become  markedly 
enlarged. 

COMPLICATIONS. 

Pneumonia  is  common,  and  is  one  of  the  common  terminal  phases. 

Laryngitis,  oedema  of  the  glottis,  and  iritis  have  been  recorded. 

Amoebic  dysentery  is  fairly  common,  and  usually  causes  death  when 
present. 

Cerebrospinal  meningitis  due  to  streptococci,  pneumococci,  or 
meningitis  is  not  uncommon. 

Epileptiform  symptoms  are  frequent. 

Helminthiasis  is  common,  but  it  may  not  give  rise  to  any  trouble- 
some symptoms.     Filaria  may  be  present. 

Malaria  is  common  in  some  districts  and  rare  in  others. 

Jiggers  and  resulting  "  tattered  toes  "  are  almost  universal.  A 
considerable  amount  of  septic  absorption  may  result  from  ulcers  caused 
by  them. 

DIAGNOSIS. 

The  finding  of  the  trypanosome  is  conclusive. 

Always  suspect  Trypanosomiasis  when  fevers  are  not  controlled  by 
large  doses  of  quinine  in  a  trypanosome  district. 

Look  for  erythema  in  Europeans.  There  will  be  a  rapid  pulse 
during  the  apyretic  periods.  Asthenia  without  wasting  should  arouse 
suspicions.  Deep  hyper^esthesia ;  Kerandal's  symptom  is  common  in 
Europeans.  Tremor  of  the  tongue;  Low  and  Castellani's  symptom 
should  be  looked  for. 

Cervical  adenitis,  Winterbottom's  sign,  is  common  and  important. 

Search  the  blood  for  trypanosomes,  auto-agglutination,  mono- 
nucleosis, but  remember  that  auto-agglutination  is  also  present  in 
Filariasis,  Malaria,  Syphilis  and  Yaws. 


AFRICAN   TRYPANOSOMIASIS  147 

In  searching  for  trypanosomes,  the  following  methods  are  avail- 
able :  — 

(i)  The  peripheral  blood,  fresh  blood  films.  Stained  blood  better 
for  details  of  parasite,  but  less  frequently  successful. 

(2)  Scarification  of  the  epidermis.  Examine  resulting  lymph  for 
the  trypanosomes.     Not  very  successful. 

(3)  Citrated  blood,  centrifuged  repeatedly.  Examine  the  third  sedi- 
ment.    The  results  are  better. 

(4)  Centrifuge  citrated  blood  in  small  tubes  and  examine  the  leuco- 
cytic  layer.     Button  and  Todd's  method. 

(5)  Puncture  the  glands  and  examine  the  juice.  The  glands  are 
often  small  and  natives  object  to  the  puncture.     A  valuable  method. 

(6)  Centrifuge  cerebro-spinal  fluid  for  15  minutes,  examine  sediment 
fresh  and  stained.  It  is  negative  in  febrile  but  positive  in  sleeping 
sickness  stage.     A  valuable  method,  introduced  by  Castellani. 

(7)  Inoculate  susceptible  animals.  Use  20  c.c.  of  blood  or  cerebro- 
spinal fluid  and  inject  it  into  monkeys  or  guinea-pigs,  dogs  or  white 
rats.  Monkeys  and  white  rats  are  soonest  killed  in  positive  cases. 
See  p.   132. 

PROGNOSIS. 

It  is  always  serious. 

It  is  curable  in  the  febrile  stage  but  not  in  the  sleeping  sickness 
stage.  All  Rhodesian  cases,  febrile  and  later  stages  have  remained 
uncured  hitherto.  There  is  one  queried  case  of  recovery  diagnosed  in 
May,  1913.  Of  500  trypanosome  cases  invalided  to  England,  300  are 
already  dead. 

Improvement  is  always  possible  except  near  the  end. 

With  treatment,  life  is  prolonged;  without  it  death  is  almost  certain. 

The  Congo  gambiense  strain  of  trypanosome  is  the  least  virulent. 

The  Uganda  gambiense  strain  of  trypanosome  is  the  more  virulent. 

The  Rhodesian  gambiense  strain  of  trypanosome  is  the  most  viru- 
lent. 

Death  is  inevitable  in  the  sleeping  sickness  stage. 

Whole  villages  have  been  depopulated  by  it  in  Senegambia,  Angola, 
Uganda  and  the  Congo.  The  populations  of  the  islands  of  Lake 
Victoria  Nyanza  have  been  annihilated  by  it. 

TREATMENT. 

Nothing  need  be  said  here  concerning  good  hygienic  conditions, 
the  exclusion  of  accompanying  diseases,  &c. 
There  is  no  specific  for  the  disease. 
vSoamin  has  not  realized  the  hopes  of  its  inventor. 


148  DISEASES   DUE    TO    PROTOZOA 

The  chief  drugs  now  reUed  upon  are  antimony  oxide,  tartar  emetic 
and  arsenic. 

Arsenical  preparations. 

Liquor  arsenicalis  has  cleared  up  some  cases.  It  was  used  before 
Soamin  was  known.  It  should  be  given  well  diluted  in  increasing 
doses,  from  5-15  minims  and  omitted  every  fifth  week. 

Salvarsan  and  Xeosalvarsan.  These  are  not  more  useful  than 
Soamin  and  much  more  costly. 

Atoxyl.  This  is  as  Soamin,  but  more  toxic,  causing  optic  atrophy, 
gastro-intestinal  inflammation,  and  peripheral  neuritus.  It  has  now 
been  replaced  by  Soamin. 

Atoxylate  of  Mercury.     Less  satisfactory  than  atoxyl. 

Soamin.     The  best  arsenical  preparation  to  use. 

The  methods  of  giving  it  are  various.  By  the  mouth,  by  the  vein 
and  intramuscular.     Examples  :  — 

3  grains  daily  per  os,  omit  every  tifth  week. 

2-3  grains  intramuscular  every  third  day  for  at  least  two  \ears. 
(Manson.) 

71  grains  intramuscularly  every  fifth  day  (Broden). 

72  grains  intramuscularly  two  successive  days  every  ten  days  for 
ten  months  (Koch). 

The  writer  has  giv^en  7^  grains  (0.50  grm.)  of  soamin  every  fifth  day 
for  two  years  without  clearing  trypanosomes  from  the  lymphatic 
glands  in  the  majority.  The  drug  was  always  suspended  on  mani- 
festations of  arsenical  poisoning.  Thousands  of  injections  were  given 
following  this  method,  but  were  abandoned  for  combined  treatment  as 
being  unsatisfactory.  Soamin  will  cause  the  disappearance  in  some 
cases  of  the  trypanosomes,  but  we  cannot  rest  contented  with  it. 

Orpiment.     An  organic  salt  of  arsenic  used  for  the  lower  animals. 

Not  any  use  in  human  trypanosomiasis. 

Galyl.  This  has  proved  useful  in  some  cases  with  tartar  emetic 
given  between  doses  of  galyl.     Useful  in  European  cases. 

Antimony  preparations. 

The  following  are  new  preparations  which  have  not  A'et  been  suffi- 
ciently tried.  They  are  :  Antileutin,  antimony  and  ammonio-potassio- 
tartras,  antimony  aniline  tartrate,  and  antimony-sodium  tartrate. 

Tartar  emetic  is  the  best  known  and  most  widelv  used. 

All  tartar  emetic  preparations  should  be  preceded  by  an  injection  of 
caffeine;  as  tartar  emetic  lowers  the  blood  pressure.  I  have  given 
thousands  of  doses  of  tartar  emetic  intravenouslv  without  anv  heart 
symptoms  of  importance. 

Tartar  emetic  is  too  painful  for  intramuscular  use.  It  was  thus 
first  used  and  abandoned  bv  Sir  Patrick   Manson   in  the  earlv  davs. 


AFRICAN   TRYPANOSOMIASIS  i49 

It  can  be  given  bv  the  month  or  rectum,  1-2  grains  in  large 
quantities  of  water,  say  1J-2  pints,  every  third  day. 

'J'artar  emetic  is  perhaps  best  given  by  the  vein,  |-i^  grains  every 
third  day.     Method  of  administration. 

I'se  a  20-c.c.  Record  sAringe.  Prepare  a  sohition  of  tartar  emetic 
so  that  10  c.c.  contain  ^  or  more  grains  of  the  drug.  Apply  a 
tournicjuet  to  the  arm  so  as  to  distend  the  veins,  paint  the  spot  with 
iodine,  draw  into  the  syringe  10  c.c.  of  the  drug,  fill  syringe  with 
boiling  water,  attach  rubber  connecting  tube,  expel  the  air,  give 
syringe  to  assistant  to  hold,  take  needle  and  plunge  it  into  the  dis- 
tended vein,  allow  a  few  drops  of  blood  to  run  through  to  ensure  that  it 
is  well  in  the  \-ein,  attach  syringe  holding  piston  end  upwards  so  that 
any  air  bubble  will  be  at  :he  upper  end,  unfasten  tournicjuet,  inject  the 
fluid  leaving-  one  c.c.  in  the  svringe,  withdraw  needle  and  empty  syringe 
through  the  needle  so  as  to  expel  any  drop  of  coagulated  blood  that 
may  be  in  the  lumen,  put  the  whole  in  a  solution  of  antiseptic  and  it 
is  ready  again  for  use.  A  little  iodine  and  bandage  on  the  site  of  the 
injection  is  sufificient.  It  is  not  necessary  to  dissect  out  the  veins 
except  in  ver\'  few  cases.  With  plenty  of  assistants  one  can  give  40 
injections  in  an  hour  in  this  wa}'.  The  reactions  \\hich  follow  tartar 
emetic  are  alwavs  marked.  Young  infected  natives  cannot  take  more 
than  h-i  grain  at  a  time  no  matter  for  how  long  the  drug  has  been 
taken.  Soamin  was  given  whh  tartar  emetic  intravenously  but  toxic 
symptoms  were  marked  and  it  was  abandoned. 

After  giving  more  than  6,000  injections  of  arsenic  and  tartar  emetic 
the  method  and  drugs  found  by  me  to  be  most  useful  up  to  the  present 
were  :  — 

A  combined  treatment  of  :  — 

One  grain  (o'o6  grm.)  of  tartar  emetic  intravenously  every  third 
day,  every  second  day  in  selected  cases. 

1-2  grains  (o"o6-o"i2  grm.)  tartar  emetic  by  the  mouth  in  a  mixture 
containing  glycerin,    sodium   bicarbonate,   and   chloroform    water. 

11^  grains  (o"jy  grm.)  soamin  intramuscularly  once  weekly.  Omit 
treatment  every  fifth  week  or  on  the  appearance  of  toxic  svmptoms. 

Arsenic  alone  tends  to  produce  arsenic-fast  trypanosomes.  One 
must  give  heroic  doses  of  whatever  drugs  one  uses.  Ascertain  the 
idiosyncrasy  of  the  patient  towards  the  drugs  and  administer  them 
just  short  of  toxic  symptoms,  omi'.ting  them  ever\'  fifth  week. 

Solutions  of  merctirv,  formalin  and  collargol  have  been  tried 
separately  and  together,  intravenouslv,  but  without  success.  Many 
natives  would  rather  die  than  have  intramuscular  injections  of  any 
kind.     They  prefer  intravenous  injections  in  spite  of  the  after  reaction. 


150  DISEASES   DUE    TO    PROTOZOA 

Attempts  have  been  made  to  procure  a  curative  and  immunizing 
serum,  but  without  success  for  man. 

It  is  interesting  to  note  that  the  physician,  Kerandal,  claims  as  his 
cure  intravenous  injections  of  tartar  emetic  given  in  four  series  of  daily 
injections  of  lo  cm.  each,  the  number  of  doses  in  each  series  being  17, 
15,  15  and  18  respectively,  or  55  in  all,  equal  to  5-50  grm.  of  tartar 
emetic.  His  weakness  disappeared  as  "  if  by  enchantment  "  after 
the  first  course  of  injections.  Atoxyl,  of  which  he  took  70  grm.  in  all, 
did  not  appear  to  affect  the  course  of  the  disease. 

PROPHYLAXIS. 

What  has  been  said  about  sanitary  measures  for  the  prevention  of 
mosquito  breeding  need  not  be  repeated  here. 

In  whatever  work  is  undertaken  the  Government  must  co-operate. 

There  should  be  medical  inspection  of  all  the  villages  on  the 
boundarv  of  the  fly  area.  Natives  must  co-operate  also,  and  this  is 
the  most  difficult  task.  If  they  do  not  volunteer  to  do  so  they  must 
be  forced.  Some  suggest  that  the  infected  should  be  isolated  and 
treated,  but  this  is  neither  practicable  nor  possible  in  the  District  du 
Kwango  of  the  Belgian  Congo,  where  about  70  per  cent,  of  the  total 
population  is  infected.  To  adopt  such  regulations  would  mean  the 
closing  down  of  all  important  works  in  that  district,  and  the  natives 
would  be  far  worse  off  than  before. 

Flv-free  areas  should  be  chosen  or  prepared,  new  villages  built 
and  maintained,  plantations  prepared  and  maintained,  all  infected 
villages  to  be  destroyed  and  the  inhabitants  removed  to  the  new  ones, 
the  infected  peoples  treated  drastically,  and  those  in  the  last  stage 
removed  to  lazarets.  This  is  a  gigantic  task,  and  is  beyond  the  purse 
of  the  Government  or  any  private  enterprise  in  Central  Africa.  It 
should  be  worked  as  far  as  possible.  The  bush  should  be  cleared  and 
planted  for  300  metres  around  every  village,  and  from  the  water's  edge 
for  100  metres.  Then  a  new  generation  of  individuals  would  arise, 
free  from  the  disease,  capable  of  increasing  their  kind  and  developing 
their  country  under  guidance  and  control. 

Fly  catching  is  impracticable  in  most  districts  to  be  of  any  real 
good . 

The  extermination  of  big  game  is,  in  my  opinion,  unadvisable. 
Wherever  man  may  go  some  animals  will  accompany  him,  and  these 
will  become  carriers  as  well  as  man. 

The  legs  of  Europeans  should  always  be  protected  with  puttees  or 
leggings  when  passing  through  fly  districts. 

European  residences  should  be  well  away  from  native  quarters. 

Quinine  does  not  seem  to  be  a  prophylactic  in  any  way. 


NOTES    ON    THE    GLOSSING 


151 


NOTES  ON  THE  GLOSSIN/E. 

The  glossing  are  limited  to  Africa  and  the  shores  of  the  Arabian 
Guh".     Formerly  they  existed  in  North  America. 

The  Genus  contains  ten   species,   which   may  be   distinguished  as 

follows  :  — 

(After  Manson.) 

GENUS  GLOSSING. 

Large  species,  length  of  body  at  least  11  mm. 

G.  longipennis.  Thorax  with  four  sharply  defined  dark-brown 
oval  spots. 

G.  pusca.     Thorax  without  spots. 

Small  species,  length  of  body  rarely  reaching  11  mm. 

Hind  tarsi  black. 

Antennae  black. 

Two  last  joints  of  front  tarsi  black. 

G.  palpalis.     Abdomen  not  very  marked. 

G.    tachinoides.      Abdomen    con- 
spicuously marked. 

All  joints  of  front  tarsi  yellow. 

G.  bocayci. 

Antennae  yellow. 

G.  paUicera, 

Two  last  joints  of  hind  tarsi  black. 

Front  and  middle  tarsi  yellow. 

G.  paUidipes. 

Front  and  middle  tarsi  black. 

Abdominal  stripe  one-third  of  seg- 
ment. 

G.  morsitans. 

Abdominal  stripe  one-sixth  of  segment. 

G.  longipalpis. 

They  are  ordinary  looking  flies  about  half  an  inch  long.  A  strong 
proboscis  stands  out  horizontally.  Both  sexes  suck  blood.  The 
wings  are  long  and  close  over  each  other  when  at  rest  like  blades  of  a 
pair  of  scissors. 

The  dorsal  aspect  of  the  abdomen  is  marked  by  five  or  more  distinct 
bands.  The  mouth  parts  consist  of  the  labrum,  labium,  hypopharynx 
or  terminal  duct  of  the  salivary  gland.  The  labrum  and  labium 
together  form  a  suctorial  tube  for  blood  and  is  called  the  labial  cavity. 
The  salivary  glands  are  long  convoluted  organs  lying  chiefly  in  the 
abdominal  segment. 


Head  of  Ghssina  longipalpis,  Wied. 
(After  Griinberg.) 


152  DISEASES   DUE   TO   PROTOZOA 

Probably  all  the  species  are  capable  of  carrying  trypanosomes. 
We  will  give  a  few  features  of  the  two  most  important. 

GLOSSINA  MORSITANS. 

This  species  was  known  first  as  a  result  of  the  writings  of 
Livingstone  and  Cummings. 

Habits. 

It  inhabits  dry  thorny  scrub,  which  covers  large  areas  of  Central 
Africa.  It  is  not  found  along  the  river  banks  or  other  water  courses ;  it 
dislikes  water.  It  requires  shade  and  is  never  found  on  the  open  plains 
exposed  to  the  tropical  sun.  It  begins  to  bite  soon  after  sunrise  on  a 
fine  day,  usually  disappears  at  mid-day,  comes  out  again  towards  sun- 
set and  is  then  very  active. 

In  rain  and  wind  they  will  remain  hidden. 

They  are  most  numerous  towards  the  end  of  the  rains. 

Food. 

Of  500  flies  examined  in  Nyasaland  the  intestines  contained  mam- 
malian blood,  chieflv  antelope's,  in  57  per  cent,  of  cases. 

They  never  suck  fruit  juices  like  the  mosquitoes. 

They  feed  once  during  30-70  hours. 

When  feeding,  the  fly  fully  distends  itself  in  I  to  i  minute  after  it 
has  punctured  the  skin.  A  male  can  absorb  it,  times  its  body  weight 
of  blood  and  a  female  r6  times  its  weight.  In  two  or  three  minutes 
after  the  feed,  minute  d'rops  of  digestive  fluids  are  exudated  from  the 
anus,  a  process  which  continues  at  the  rate  of  2  per  minute  for  20 
minutes.  Some  hours  later  a  thick  brown  excrement  follows  and  the 
abdomen  becomes  markedly  reduced  in  size. 

Reproduction. 

All  Glossinre  are  pupiparous  and  in  this  differ  from  most  of  the 
Diptera.  The  female  produces  one  white-yellowish  larva  once  in  ten 
days.  This  is  retained  in  the  oviduct  until  fully  grown.  When  born 
it  creeps  into  the  soil  or  amongst  the  leaves  and  debris  and  within  a 
few  hours  has  changed  to  a  hard,  black  puparium.  The  adult  fly 
emerges  in  about  23-60  days  according  to  temperature.  The  female 
generally  chooses  the  under  surface  of  a  tree  for  this  purpose,  generally 
near  a  native  path  or  a  game  track  so  as  to  facilitate  the  mother's 
obtaining  food  for  her  young  and  herself. 

GLOSSING  PALPALIS. 

These  are  widely  distributed.  They  are  lovers  of  water  and  are  to 
be  found  frequenting  the  edges  of  rivers,  lakes,  ponds,  water  holes  in 
banks  where  there  is  clear  water  and  plenty  of  shade,  thick  under- 
growth with  high  trees  and  dense  jungle. 

They  are  never  found  on  open  beaches  backed  by  grassy  plains  even 


NOTES    ON    THE    GLOSSIN.^ 


153 


with  scrub  near  to  the  water.  They  are  not  found  amongst  the  reed 
beds  or  papyrus  swamps  such  as  exist  in  the  Uganda  river  valleys. 
They  are  never  found  away  from  water  except  where  tiiey  have  followed 
man  or  beast  a  mile  or  so  for  his  blood. 

Habits. 

Their  bites  are  as  those  of  the  G.  morsitans.  They  flv  rapidly, 
settle  quickly  on  the  skin  and  soon  ingest  enough  blood  to  fill  them 
out  perhaps  without  a  prick  liaving  been  felt. 


Antenna  of  Glossina  pallidipes,  male. 
(After  Austen.) 


Glossina  palpalis  and  puparium. 
(After  Brumpt.) 


Feeding. 

When  a  G.  palpalis  has  fed  on  an  infected  animal  it  becomes 
infective  on  an  average  of  34  days  from  the  feed.  It  remains  infective 
for  about  75  days. 

Food. 

In  populated  districts  man  supplies  sufficient  blood  but  in  captivity 
or  at  any  time  they  will  feed  on  hot  or  cold  blooded  animals,  birds  or 
reptiles. 

Reproduction. 

vSimilar  to  G.  morsitans. 

Sandy  banks  banked  by  a  belt  of  vegetation  are  often  chosen.  The 
pup^e  are  found  one  to  two  inches  below  the  surface  of  the  ground 
amongst  or  near  to  vegetation. 

There  is  no  hereditary  transmission  of  trypanosomes  in  the  tissue, 
all  trypanosomes  are  obtained  from  the  animals  they  feed  upon. 


154 


DISEASES  DUE   TO   PROTOZOA 


SOUTH   AMERICAN  TRYPANOSOMIASIS. 

HISTORY,  &c. 

This  disease  is  caused  by  Trypanosoma  cruzi  discovered  by 
Chagas  in  1909. 

It  is  spread  by  the  bug  Lamus  megistus  and  alHed  forms. 

Its  reservoir  is  probably  in  the  Armadillo,  Dasypus  novemcinctus. 

The  bugs  live  in  the  burrows  of  the  armadillo. 

The  disease  is  only  known  amongst  the  poorer  inhabitants  of  the 
State  of  Minas  in  Brazil  where  it  appears  to  attack  the  whole 
population. 

iETIOLOGY. 

The  Trypanosoma  cruzi  has  a  large  kineto  nucleus. 
It  is  found  in  domestic  animals  and  man. 


Trypanosoma  cruzi.  Schizogony.  /,  merozoite  in  rei  blood  corpuscle ;  2,  parasite 
totally  enclosed  in  red  cell,  no  flagellum  or  undulating  membrane  ;  j-j",  parasites  partially 
enclosed  in  red  cell  ;  6,  7,  parasites  in  human  blood  ;  Sir,  parasites  in  lungs  of  the  monkey, 
Callithrix  ;  12,  ij,  initial  forms  of  schizogony  ;  14,  /j,  schizogony  in  the  lungs  of  Callithrix. 
(After  Chagas.) 


Three  forms  of  the  trypanosome  are  seen   in   man  :  — 
(i)  With  a  large  nucleus,   loose  chromatin  and  a  terminal  kineto 
nucleus. 

(2)  A  narrower  form  with  an  oval  nucleus  and  dense  chromatin. 

(3)  A  form  with  an  elongated  nucleus. 

The  trypanosome  undergoes  multiplication  in  one  of  three  ways  :  — 
(i)  Schizogony . — This  takes  place  in  the  capillaries  of  the  lungs 
of  the  callithrix  where  it  loses  its  flagellum  and  undulating  membrane, 
it  curves  itself  and  forms  a  disc  which  divides  into  eight  merozoites. 
These  enter  the  red  cells  and  become  adult  trypanosomes.  Later 
they  leave  the  red  cells  and  live  free  in  the  blood-stream.  Schizogony 
probably  differentiates  sexual  forms  and  lays  the  basis  for  infection 
of  invertebrate  hosts. 


SOUTH   AMERICAN  TRYPANOSOMIASIS  155 

(2)  Sporogony. — This  takes  place  in  the  bug  Lamus  magistus. 
Sexual  and  asexual  forms  develop,  the  final  stage  of  development 

being  found  in  the  salivary  glands  when  they  are  ready  to  infect  a  new 
vertebrate  host.  The  development  in  the  gut  requires  about  eight 
days . 

(3)  Agaviony. — This  is  an  asexual  form  of  reproduction  and  takes 
place  in  the  cells  of  the  various  organs  of  the  callithrix,  i.e.,  in  the 
hypertrophied  endothelial  cells  of  the  lungs,  in  the  cardiac  muscle, 
in  striped  muscle  and  in  the  neuroglia  of  the  central  nervous  system. 
In  these  situations  it  appears  as  a  rounded  body  but  without  flagellum 
or  undulating  membrane. 

The  trypanosome  is  not  known  to  undergo  any  longitudinal 
division  in  the  peripheral  blood  or  the  internal  organs  of  the  host. 

The  trypanosome  is  easily  cultivated  on  blood  agar. 

The  Lamus  is  infective  to  vertebrates,  8-10  days  after  an  infective 
feed  and  remains  infective  for  a  long  time. 

PATHOLOGY. 

The  trypanosome  enters  the  body  cells,  especially  of  the  muscle, 
more  frequently  about  the  back  and  extremities.  In  these  cells  it  assumes 
a  Leishmania-like  form  without  flagellum  but  with  a  tropho-kineto 
nucleus.  Division  is  by  binary  fission,  the  two  daughter  cells  dilat- 
ing the  mother  cell,  or  more  correctly,  the  cyst  membrane  which 
ruptures,  liberating  the  two  enclosed  forms.  The  parasites  now 
become  flagellates  and  move  about.  Local  inflammation  now  sets  in 
with  the  presence  of  trypanosomes  in  the  blood.  There  may  also  be 
a  production  and  liberation  of  toxins  because  the  liver  undergoes  fatty 
degeneration. 

Different  organs  may  be  attacked  in  this  way,  the  local  symptoms 
and  pathological  changes  being  in  accordance  with  the  organ  or 
organs  selected. 

P.  M.  :  MACROSCOPIC. 

There  is  serous  effusion  into  the  abdomen. 

The  liver  is  enlarged  with  fatty  degeneration. 

The  spleen  is  enlarged,  hyper^mic  and  soft. 

The  mesenteric  glands  are  enlarged,   hypera^mic  and  soft. 

There  is  serious  effusion  into  the  pleural  cavities. 

The  same  condition  affects  the  pericardial  sac,  there  may  also  be 
hjemorrhagic  pericarditis. 

The  heart  may  be  much  enlarged,  there  may  be  intense  myo- 
carditis. 

The  lymphatic  glands  are  swollen  and   h_yper£emic. 

The  thyroid  gland  is  enlarged. 

The  dura  mater  is  congested.     There  may  be  signs  of  leptomenin- 


156 


DISEASES   DUE   TO   PROTOZOA 


Trypanosoma  criizi.  Trans- 
verse section  of  a  striated 
muscle  containing  rounded 
forms  of  the  parasite  in  the 
central  portion.  x  1,000 
approx.      (After  Vianna.) 


gitis,  encephalomeningitis,  adhesions  between  the  leptomeninges  and 
the  cerebral  cortex. 

The  cerebro-spinal  fluid  is  increased. 

A  general  myxocdematous  condition  is  usually  present  under  the 
skin. 

MICROSCOPICALLY. 

Trypanosomes  are  foimd  in  the  heart 
muscle  destroA'ing  the  sarcoplasm  and  con- 
verting the  muscle  cells  into  cysts,  ^\hich 
rupture  and  discharge  their  contents  into  the 
intermuscular  tissues  and  causing  patches  of 
interstitial   myocarditis. 

There  are  often  signs  of  peri-  and  endo- 
carditis present. 

The  central  nervous  svstem  is  affected  in 
a  similar  manner,  but  it  is  a  neuroglial  cell 
that   is  invaded. 

The   suprarenal    capsule,    kidneys   or  thy- 
roid gland  may  be  similarly  affected. 
SYMPTOMATOLOGY. 

Acute. — There  is  a  violent  attack  of  fever  in  a  child  or  a  new- 
comer. 

The  fever  shows  a  morning  remission  and  an  e\'ening  rise. 

The  thyroid  gland  enlarges. 

The   face  becomes  o^dematous   whh   characteristic  crepitations. 

The  lymphatic  glands  enlarge,  especially  in  the  neck. 

There  may  be  fugitive  cx^demas  of  any  part. 

The  spleen  enlarges  and  becomes  painful. 

The  same  takes  place  \\  ith  the  liver. 

Sometimes  there  are  signs  of  meningitis. 

Sometimes  there  is  albumin  in  the  urine. 

The  fever  passes  off  to  recur  at   intervals. 

During  the  attack  trypanosomes  are  found  in  the  blood. 

The  child  eventually  dies,  recovers  or  the  condition  becomes  :  — 

Chronic. — There  is  marked  thyroiditis  accompanied  by  loss  of 
hair.  Mypertrophy  of  tiie  lymphatic  glands  continues.  There  is  a 
dull  expression,  a  bluish-bronze  tinge  to  the  skin,  tach}-cardia, 
intestinal  and  nervous  disorders,   convulsions. 

Chagus  says  that  the  chronic  stage  may  show  group  s\'mptoms 
;is  :  — 

(i)  Psciido-myxoedcmatous. 

There  is  hypertrophy  of  the  lateral  lobes  of  the  thyroid  gland  in 


PATHOLOGICAL  MAMMALIAN  TRYPANOSOMIASIS  i57 
quite  young  but  not  in  older  children.  A  peculiar  bronze  colour  of 
the  skin  probably  due  to  the  invasion  of  the  suprarenal  capsule.  The 
lymphatic  glands  enlarge  in  the  neck,  axilhe,  groin  and  the  parotid 
also. 

(2)  Myxoedematous . 

The  thyroid  gland  atrophies  with  the  usual  classical  symptoms  of 
myxoedema,  e.g.,  rough  skin,  loss  of  hair,  firm  oedema,  arrest  of 
mental  development  in  younger  children,  mental  degeneration  of  older 
ones.     There  may  be  inflammatory  eye  troubles. 

(3)  Cardiac. 

There  is  arrhythmia,  alarrhythmia,  extra  systole,  sinus  irregularities. 

(4)  Nervous. 

Spastic  paralysis  in  the  legs. 

Athetosis  in  the  arms. 

Aphasia,  pseudo-bulbar  paralysis,  suprabulbar  paralysis. 

(5)  Chronic  with  acute  and  sub-acute  exacerbations. 
Preponderance  of  fever. 

This  variety  causes  a  heavy  mortality. 
The  parasites  are  rarely  found  in  the  blood. 
It  has  a  long  history. 

It  usually  occurs  in  patients  showing  marked  enlargement  of  the 
thyroid  gland.     Infantilisms  may  be  sequelae  of  the  disease. 

TREATMENT. 

As  for  African  Trypanosomiasis. 

Also  treat  for  hyperthryoid^e  and  symptomatically. 

PROPHYLAXIS. 

Aim  at  the  prevention  of  the  bites  of  Lamus  magistus. 

NOTES   OX    PATHOLOGICAL    MAMMALIAN 
TRYPANOSOMIASIS. 

TRYPANOSOME   EYANSI. 

It  causes  surra  in  horses,  mules,  camels  and  cattle. 

It  occurs     in     India,     Burmah,     Indo-China,     Java,     Philippines, 
Mauritius  and  North  Africa. 

The  symptoms  are  :  fever,  emaciation,  oedema  of  the  extremities 
and  of  the  ventral  surface,  eye  lesions,  great  muscular  weakness, 
paralysis  and  death. 

The  treatment  is  by  arsenic  in  big  doses. 

It  is  transmitted  by  the  bites  of  flies  and  fleas.     Some  suggest  by 
the  ingestion  of  infected  meat  also. 

TRYPANOSOME  BRUCEI. 

It  causes  nagana  (weakness). 

It   occurs   in   Zuzuland,    North   Transvaal,    Pretoria   to  Nyasaland, 


158  DISEASES  DUE    TO   PROTOZOA 

the  basin  of  the  Limpopo,  German  East  Africa,  British  East  Africa 
and  Uganda. 

The  carrier  is  Glossina  morsitans  and  the  Tabanidas. 

The  trypanosome  gives  rise  to  :  — 

An  acute  disease  in  mice,  rats,  dogs,  monkeys  and  cats. 

A  subacute  disease  in  rabbits,  guinea-pigs,  equines  and  pigs. 

A  chronic  disease  in  cattle,  goats,  geese  and  fowls. 

It  is  fatal  to  horses,  asses  and  dogs. 

The  symptoms  are  :  fever,  infiltration  of  coagulable  lymph  in  the 
subcutaneous  tissues  of  the  neck,  abdomen  and  extremities,  rapid 
destruction  of  the  red  cells,  extreme  emaciation,  and  often  blindness. 

The  treatment  is  by  arsenic. 

TRYPANOSOME  EQUINUM. 

It  causes  mal  de  caderas,  a  disease  of  the  hind  quarters  in  horses 
and  dogs  in  South  America. 

It  is  spread  by  the  ingestion  of  the  infected  meat  of  dogs,  also  by 
fleas.     Some  blame  the  Tabanid^e  and  Stomoxys. 

It  is  very  fatal  to  horses. 

The  symptoms  are  :  rapid  weakness,  fever,  paralysed  hind  quarters, 
staggering  gait,  stumbles  and  falls.  Albuminuria,  h^ematuria, 
eruption  on  the  neck,  shoulders  and  hind  quarters  not  uncommon. 
Conjunctivitis  and  chemosis.  There  are  serous  exudations  into  the 
serous  cavities  and  the  spinal  canal. 

A  mare  will  die  in  two  months  after  the  paralysis  begins. 

TRYPANOSOME   EQUIPERDUM. 

It  causes  dourine  or  mal  du  coit  in  horses. 

It  occurs  in  Europe,  India,  North  Africa,  and  North  America. 

It  is  spread  by  coitus  between  stallion  and  mare,  not  by  flies,  hence 
the  trypanosome  is  capable  of  penetrating  a  healthy  mucous  membrane. 

The  incubation  is  eleven  to  twenty  days. 

The  symptoms  are  :  oedema  of  the  genitals,  which  is  painless;  it  is 
not  inflammatory;  there  is  some  fever;  this  lasts  one  month,  when 
weakness  and  emaciation  begin. 

An  eruption  comes  in  about  forty  to  forty-five  days,  in  circular 
areas,  with  oedema  about  the  flanks,  hind  quarters,  neck,  shoulders 
and  thighs.     It  is  often  transient,  and  lasts  about  one  week  in  all. 

There  is  synovial  engorgement  of  the  joints  and  tendon  sheaths. 

There  is  enlargement  of  the  lymphatic  glands,  particularh^  of  the 
inguinal  glands. 

Anaemia  and  paralysis  then  set  in.  The  mucosae  are  pale,  and 
marked  emaciation  is  rapid.  There  are  superficial  abscesses,  non- 
healing in  character,  conjunctivitis,  ulcerative  keratitis. 


ESSENTIALS   OF   TROPICAL   MEDICINE. 


(a)  T.  lewisii.     The  antiflagellar  end  is  sharply  pointed,  the  centrosome  usually  at  some  little  distance 
from  the  end  of  the  body,  and  the  nucleus  is  always  in  the  flagellar  half  of  the  body.     Size  25  to  30  ;U. 


(b)   T.  gamlnense.     The  antiflagellar  end  is  usually  bluntly  rounded,  the  centrosome  close  to  that  end, 
and  the  nucleus  at  the  middle  of  the  body.     Size  20  to  25  yU. 


(:)   T.  nanum.     Characterized  by  its  small  size,  being  only  about  14  jx  in  length.     The  centrosome  is 
small  and  the  nucleus  is  round  and  in  the  centre  of  the  body. 

(d)   T.  theileri.     Characterized  by  its  large  size,  being  some  65  fx  in  length. 


>> 


I 


(e)  T.  dimortikon.  The  important  characteristics  of  this  type  are  the  broad  body,  the  short  free  portion 
of  the  flagellum,  the  closeapplicationof  the  undulating  membrane  to  the  body  and  the  presence  of  a 
vacuole  between  the  centrosome  and  nucleus. 

bfcilu  &  D-.,r.ulr,soi.  .L^'*-  del.et  htli 


Face  page  158- 


PATHOLOGICAL    MAMMALIAN    TRYPANOSOMIASIS     159 

Micturition  is  difficult ;  the  urine  is  thick. 

SensibiUty  is  diminished,  paralysis  comes  on  due  to  softening  of 
the  cord.     The  animal  dies  in  two  to  eighteen  months  from  the  onset. 

The  disease  is  always  fatal. 

The  condition  may  be  more  acute  than  as  described,  with  death 
after  a  few  days  from  the  eruption  from  acute  paralysis. 

TRYPANOSOME  CAZALBOUI  (T.  vivax  of  Bruce). 
It  causes  disease  in  horses  and  cattle  in  West  Africa. 
It  is  carried  by  Glossinae. 

TRYPANOSOME  SOUDANESE  (T.  evansi  of  Bruce). 
It  causes  tahaga  in  dromedaries  and  zausfana  in  horses. 
The  former  disease  occurs  in  the  Upper  Niger,  and  the  latter  in 
Southern  Algeria. 

It  is  carried  by  the  Tabanidas. 

TRYPANOSOME  HIPPICUM. 

It  causes  murrina  amongst  mules  in  North  America. 
It  is  spread  by  flies  which  suck  wounds  and  by  coitus. 


Trypanosoma  leivisi.     Multiplication  rosettes,      x   i,ooo.     (After  Laveran  and  Mesnil.) 

TRYPANOSOME  CONGOLENSE. 

It  causes  trypanosomiasis  amongst  horses,  cattle,  goats,  sheep  and 
dromedaries  in  French  and  Belgian  Congo,  N.E.  Rhodesia. 
It  is  carried  by  the  Glossinas. 


i6o  DISEASES  DUE   TO   PROTOZOA 

TRYPANOSOME  DIMORPHON. 

This  attacks  cattle,  dogs,  sheep,  pigs  and  goats  in  several  parts  of 
Africa.     It  is  carried  by  the  Glossina  palpalis. 

In  the  horse  there  is  loss  of  vigour,  in  two  or  three  weeks  there  is 
fever,  the  next  month  there  is  marked  weakness,  abdominal  swelling,, 
the  testicles  hang  down  and  are  oedematous,  the  coat  is  staring,  the 
whole  appearance  is  apathetic.  There  is  fluid  in  the  serous  cavities- 
Death  takes  place  in  about  one  year. 

There  is  hypertrophy  of  the  glands,  fatty  liver  and  congested  lungs. 

Probably  the  T.  pecorum  of  Bruce  includes  the  T.  dimorphon, 
congolense  and  confusum  of  the  above  descriptions.  The  point  is  still 
suh  judice. 


SECTION    II. 
DISEASES    DUE    TO    BACTERIA. 

GENERAL    FEATURES    OF    BACTERIA 
PLAGUE. 

Notes  on  Fleas. 
LEPROSY. 
PSITTACOSIS. 
UXDULAXT    FEVER. 
BACILLARY    DYSENTERY. 
CHOLERA. 

ENTERIC    FEVER    OF    THE    TROPICS. 
Flies  and  Disease. 


II 


i62  DISEASES   DUE   TO    BACTERIA 

DISEASES     DUE     TO     BACTERIA. 

GENERAL  FEATURES  OF  BACTERIA. 
(After  E.  W.  Hey  Groves.) 

GENERAL   CHARACTERS. 

Fission     fungi.     Devoid     of     chlorophyl.     Unicellular     vegetable 
organisms.     Consist  of  protoplasm  surrounded  by  a  cell  wall. 

REPRODUCTION. 

(a)  By  simple  fission. — The  common  method. 

(b)  By  Spore  formation. — Only  found  in  a  few  bacilli. 
Never  found  in  common  pyogenic  bacteria. 

Occurs,  e.g.,   in  B.  anthracis,   B.  tetani,    B.  cx^dematis  maligni. 

Spores  are  formed  when  conditions  for  bacterial  life  are  un- 
favourable. They  have  a  thick  capsule,  and  are  very 
strongly  resistant  to  desiccation,  heat,   or  antiseptics. 

(c)  By  budding,  e.g.,  yeast. 

LOCOMOTION. 

Passive. — By  Brownian  movement,  physical  or  chemical  currents. 
Active. — By     flagelUe,      i.e.,      actively      contractile      protoplasmic 

processes. 

Found  in  B.  typhosus  and  B.  coli. 

SHAPE. 

Cocci.     Round;  never  produce  spores.     Gram    + 
Staphylococci ;  arranged  irregularly. 
Diplococci ;  arranged  in  pairs. 
Streptococci  ;  arranged  in  chains. 
Tetracocci ;  arranged  at  four  corners  of  a  square. 
Sarcin^e ;  B.  arranged  at  eight  corners  of  a  cube. 
Bacilli.     Rod  shaped,  often  spore-bearing.     Gram   +  and  — . 
Streptobacilli ;  chains  of  bacilli. 
Leptothrix;   long  threads. 
Spirilla;  spirally  curved. 

PHYSIOLOGY. 

They  require  organic  proteids  for  food  because  they  have  no 
chlorophyl. 

Parasites  obtain  it  from  living  animals  or  plants. 

Saprophytes  obtain  it  from  dead  tissues. 

Facultative  parasites  ordinarily  live  on  dead  tissues,  but  can  also 
grow  in  living,  e.g.,   B.  proteus. 


GENERAL  FEATURES   OF   BACTERIA  163 

Facultative  saprophytes  ordinarily  live  in  living  tissues,  but  can 
with  difficulty  be  cultivated  outside,  e.g.,  gonococci. 

Conditions  necessary  for  bacterial  existence  or  activity. 

Proteid  food  in  an  assimilable  form.  Water.  Temperature  at  or 
about  blood  heat.     Darkness.     Oxygen  or  its  absence. 

Aerobes,  e.g.,  pyogenic  cocci,  require  oxygen. 

Anaerobes,  e.g.,  B.  tetani,  cannot  live  in  oxygen.  But  they  can 
often  live  in  company  with  other  bacteria  which  absorb  oxygen  even  in 
the  presence  of  air;  e.g.,  B.  tetani  can  grow  in  a  surface  wound  if  it  is 
contaminated  by  cocci. 

Conditions  causing  a  suspension  of  bacterial  activity  or  groivth. 

Absence  of  pabulum.     Dryness.     Cold.     Sunlight. 

Conditions  causing  bacterial  death. 

Heat  at  or  below  boiling  pomt  quickly  kills  all  except  spores. 

Spores  require  temperature  of  25o°F.  or  long  boiling  to  kill. 

Chemical  reagents,  e.g.,  carbolic  acid,  mercury  salts,  etc.,  must  be 
of  a  certain  strength  ;  act  for  a  certain  time  and  come  into  intimate 
contact. 

In  all  conditions  in  which  the  living  tissues  are  more  potent  than 
the  bacteria. 

Products  of  bacterial  activity  ivhe7i  growing  in  living  tissues. 

Acids  or  alkalies,  e.g.,  B.  coli  produces  an  acid. 

Gases  (rare),  e.g.,  B.  coli  and  B.  oedematis  maligni. 

Pigments  (rare),  e.g.,  B.  pyocyaneus. 

Aromatics.     Indol,  phenol.     Alcohols. 

Ferments.     Diastase,   curdling  ferment,   proteolytic  ferment. 

Ptomaines.     Crystallizable  alkaloids. 

Toxins.     The  specific  poisons,  probably  albumoses. 

(a)  Intracellular  toxins,  e.g.,  tuberculosis.  The  toxin  remains 
closely  associated  with  the  bacillus,  and  only  acts  in  its 
neighbourhood. 

(b)  Extracellular  toxins,  e.g.,  diphtheria,  tetanus. 

The  toxin  is  found  in  the  bodv  fluids,  and  acts  at  a  distance  from 
the  bacteria. 

THEORIES  OF  IMMUNITY. 

The  tissues  acquire  two  methods  of  defence. 

(i)  They  kill  the  bacteria;  antibacterial  action. 

(2)  They  neutralize  the  toxins;  antitoxic  action. 

Antitoxic  action  is  an  actual  chemical  antithesis  to  the  toxin 
produced  in  the  blood  bv  infection. 

lliis  is  a  proteid,  and  is  called  antitoxin  :  it  can  be  made  to 
neutralize  the  toxin  outside  the  body. 

Best  exemplified  in  diphtheria  and  tetanus. 


104  DISEASES   DUE   TO    BACTERIA 

Anli-bacterial  action  is  brought  about  by  two  agencies  :  — 

(i)   Phagocytosis.     The  leucocytes  digest  the  bacteria. 

(2)  Action  of  anti-bacterial  substances  in  the  blood  serum  which  kill 
and  dissolve  the  bacteria  outside  the  leucocytes. 

Bacteriolysins.  Exemplified  in  anti-streptococcus,  anti-cholera, 
anti-plague,  anti-pneumococcus,  and  anti-typhoid  sera. 

Phagocytes.  Is  increased  by  the  action  of  a  substance  called 
an  opsonin  produced  by  the  action  of  the  bacteria  and  the  toxins  in  the 
blood. 

Opsonic  Index  is  the  proportion  of  bacteria  devoured  by  leucocytes 
m  an  infected  blood  to  those  devoured  by  leucocytes  in  normal  blood. 

Directly  after  an  injection  of  a  vaccine  (bacteria  of  toxins)  the 
opsonic  index  falls  =  negative  opsonic  phase.  During  this  time  a 
further  dose  of  vaccine  does  harm. 

After  a  few  days  the  opsonic  index  rises  --  positive  opsonic  phase. 
During  this  time  a  further  dose  of  vaccine  increases  the  phagocytosis. 

DISTRIBUTION. 

In  air  and  water.  Plentiful  in  proportion  to  warmth  and  proximity 
to  organic  life. 

In  earth.     Always  abundant  near  the  surface. 

In  animals  (apart  from  disease). 

On  and  in  the  skin,  hair  follicles,  and  sweat  glands. 

Mouth,  especially  round  the  teeth. 

Whole  alimentary  canal.  Most  numerous  at  the  end  of  the  small 
and  beginning  of  the  large  intestine. 

Lower  parts  of  the  urethra,  vagina  and  nose. 

INFECTION. 

The  invasion  of  the  living  tissues  by  bacteria  in  such  a  manner  as 
to  produce  local  or  general  disease. 

CONDITIONS  NECESSARY  FOR  INFECTION, 

(i)  Dose  of   bacteria.     Bacteria    must  be    introduced    in  a    certain 

number,    or  they    will  be    destroyed    before    they  produce    any 

effect. 
(2)  Virulence. — This  varies  enormously  naturally. 

May  be  increased  artificially  :      By  passage  through  successive 

animals. 

May  be  decreased  artificially  :     By  cultivation  outside  the  body, 

especiall}^  if  done  under  unfavourable  conditions. 
f,3)  Pathogenicity. — Only  certain  kinds  of  bacteria  are  capable  of 

producing  disease  in  certain  kinds  of  animals. 


PLAGUE  165 

(4)  Susceplibiliiy    of   llie    host — i.e.,    :\    vulnerability    of    the    living- 
tissues  by  the  bacteria. 

Increased  by  :  Any  constitutional  depression,  cold  or  wet, 
starvation,  youth  of  the  patient,  alcoholism,  narccjtics  and  con- 
stitutional diseases,  e.g.,  Bright's  disease  or  diabetes. 

(5)  Entrance  of  the  bacteria  into  the  tissues,  provided  by  :  — 

(a)  A  wound  or  abrasion  or  ulcer,  (b)  An  inflamed  or  injured 
part,  e.g.,  an  inflamed  tonsil  or  a  sprained  joint,  (c)  Pro- 
found constitutional  depression,  allowing  the  normally 
present  bacteria  to  enter  and  multiply  in  tiie  tissues. 

IMMUNITY. 

Is  a  condition  of  absolute  or  relative  insusceptibility  of  the  indivi- 
dual to  infection  after  invasion  by  virulent  pathogenic  bacteria.  There 
are  two  varieties  : — • 

Natural  Immunity. — Racial  or  individual. 

Acquired  Immunity. — Active  immunity;  passive  immunity. 

Natural  Imiuuuily. — Nature  of  the  condition  is  not  known.  No 
antitoxic  or  antibacterial  substance  can  be  separated  from  the  blood. 

Is  lessened  by  cold  or  wet,  starvation,  youth,  hcTmorrhage, 
alcohol  and  poisons. 

Active  Immunity. — ^Caused  by  a  previous  infection,  either  as  the 
natural  or  modified  disease. 

Involves  an  actual  illness.  Takes  time  for  its  development.  Lasts 
many  }'ears. 

Is  brought  about  by  :  — 

(a)  Previous  attack. 

(b)  Giving  the  disease,  e.g.,  old-fashioned  inoculation  of  small-pox. 

(c)  Injection  of  attenuated  virus,  e.g.,  vaccination  for  small-pox, 
anthrax  (in  cattle),  hydrophobia. 

(d)  Injection   of  dead  bacteria,   e.g.,   plague,   typhoid,   tuberculosis. 

(e)  Injection  of  toxins,  e.g.,  in  the  animals  which  provide  the  anti- 
toxins of  diphtheria  and  tetanus. 

Passive  Iniinunity. — Caused  bv  injecting  the  blood  of  an  actively- 
immunized  animal.  Involves  no  illness.  Follows  immediately  on 
injection.     Onlv  lasts  a  few  months. 

Is  most  successful  against  extracellular  loxins,  e.g-.,  diphtheria  and 
tetanus. 

PLAGUE. 
DEFINITION. 

A  septicaemia  caused  b\'  the  Bacillus  pestis,  spread  amongst  men 
and  other  animals  by  fleas,  characterized  1)\'  fever,  rapid  course,  and 
high  mortality. 


i66  DISEASES   DUE   TO    BACTERIA 

HISTORICAL  FEATURES. 

There  is  a  coin  of  Lucius  Severus  showing  ^sculapius,  God  of 
Medicine,  witli  the  feel  on  a  dead  rat  and  a  nude  human  figure  in  terror 
by  his  side. 

The  Greeks  worshippeci  a  rat-kiUing  Apollo  who  was  reputed  to 
bring  and  remove  plague  epidemics. 

1 140  B.C.  the  Bible  records  an  epidemic  in  the  country  of  the 
Philistines  which  produced  buboes  in  man  and  killed  rats  (mice  of  the 
field),  when  50,070  men  died  (i  Sam.  v.  4). 

7/0  B.C.  perhaps  Sennacherib's  army  was  attacked  by  a  similar  pest 
(2  Kings  xix.  35). 

:;42  A.D.  there  was  an  outbreak  in  Pelusium,  a  great  Egyptian 
market,  whence  it  spread  to  Byzantium,  the  City  of  the  World,  into 
Asia,  North  Africa,  Western  Europe,  Ireland,  lasting  in  epidemic 
form  about  200  years. 

iitli  to  14th  century  it  was  pandemic,  declining  and  leaving 
Western  Europe  in  the  17th  centur}'. 

740J  A.D.  the  Venetians  erected  the  first  lazaretto  for  the  isolation 
of  the  sick  by  a  quarantine  of  forty  davs,  also  disinfecting  clothing 
and  merchandise.  A  yellow  flag  was  to  be  hoisted  by  ships  coming 
from  a  foreign  port,  and  both  crcAv  and  passengers  inspected. 

The  sacred  Hindoo  book,  the  "  Bhagavat  Purana,"  believed  to  be 
800  \-ears  old,  speaks  of  plague  in  India.  It  advises  the  vacation  of 
the  house  wherein  dead  rats  were  found.  It  is  now  endemic  in  India. 
There  were  epidemics  :  — 

182^,   in  Delhi. 

i8j6  in  Rajputana  and  in  Rohilcund,  the  Pali  Plague,  at  the  same 
time. 

ifj6-i8og  it  was  introduced  into  China  by  Mohammedans  returning 
from  Mecca.  Since  endemic  in  Junnan,  it  has  spread  southwards, 
reaching, 

i86y,   Pakhoi. 

iSqz}.,  in  June,  Kitasato  found  the  Bacillus  pestis  in  Hong-Kong. 

i8g6  it  spread  from  China  to  Bombay,  hence  over  India. 

i8g8  the  pandemic  spread  from  India  to  Madagascar  and  Mauritius. 

i8gg,  Malay  States,  Philippines,  Australia,  United  States,  South 
America. 

I  goo,  Capetown,  Glasgow. 

igo'/,  almost  world-wide. 

Tripoli  and  Uganda  are  endemic  areas  in  Africa. 

igog,  in  ]\Ianchuria,  the  pneumonic  form  was  prevalent.  The  hot 
season  of  the  tropics  and  the  winter  of  the  Temperate  Zone  are  dele- 
terious to  its  spread.     The  bacilli  rapidly  disappear  from  the  stomach 


PLAGUE  167 

of  the  flea  above  85°  F.;  at  10°  F.  they  are  virulent.  High  tempera- 
ture causes  adult  fleas  to  refrain  from  laying  eggs  and  prevents  larva; 
from  developing.  Below  50°  F.  fleas  do  not  become  infected  when 
sucking  blood. 

1896-1905.  During  these  ten  years  in  Bombay,  1,154,613  people 
died  of  plague.  Hygienic  conditions  have  forced  plague  back  from 
Europe,  where  it  was  once  more  prevalent  than  in  the  tropics. 

From  1896  to  191 2  plague  in  India  killed  7,000,000,  or  about  7  per 
minute. 

1664-1679,  the  last  time  plague  was  in  England,  70,000  people  died 
in  London. 

The  effect  made  upon  English  national  life  by  this  attack  was  most 
marked.  Everv  English  hedgerow  is  a  reminder  of  plague;  they  mark 
the  change  in  land  tenure  which  followed  the  Black  Death.  The  loss 
of  labour  by  the  plague  drove  out  villeinage  and  serfdom,  after  which 
it  became  necessary  to  define  the  fields.  From  that  period  dates  the 
emancipation  of  the  English  labouring  classes. 

Plague  helped  to  kill  the  textile  industries  of  the  Eastern  Counties, 
and  laid  the  foundations  of  the  modern  prosperity  of  Lancashire  and 
Yorkshire. 

It  facilitated  the  growth  of  English  literature.  L'^p  to  the  time  of 
the  plague  French  was  the  principal  language  of  the  schools  and  the 
wealth V,  but  so  manv  teachers  died  in  the  epidemic  that  a  new  race 
of  English  teachers  arose. 

1802,  Whyte  communicated  it  to  himself,  and  died  while  conduct- 
ing an  experiment. 

iSj-;,  at  Cairo,  two  condemned  criminals  were  inoculated,  but 
recovered. 

i8g8,  in  a  Vienna  laboratory,  the  pneumonic  type  was  contracted 
from  cultures.     There  was  no  epidemic  present. 

Plague  does  not  spread  v.ell  in  sanitary  districts. 

It  is  not  nearlv  as  contagious  as  small-pox  and  scarlet  fever. 

1910-1911.  The  Plague  in  China  was  of  the  pneumonic  type,  the 
most  severe.  The  great  majority  of  the  natives  and  Europeans 
attacked  died,  about  46,000  in  all.  The  epidemic  was  brought  by  the 
hunters  of  the  marmot,  which  is  an  animal  susceptible  to  epizootic 
plague. 

The  disease  was  spread  bv  the  hunters  when  they  returned  home. 

No  instance  of  plague  was  found  amongst  the  rats  examined. 

Rats  are  undoubtedly  to  blame  in  India  and  elsewhere.  Their 
extermination  is  a  problem.  At  Tokio,  during  five  years,  there  were 
4,800,000  rats  killed  at  a  considerable  financial  outlay,  but  even  then 
there  was  not  any  reduction  noticed  in  the  rat  population. 


i68  DISEASES   DUE   TO    BACTERIA 

The  isolated  cases  of  pneumonic  plague  which  occur  in  Siam  do 
not  appear  to  have  any  tendency  to  cause  extension  of  the  disease, 
and  persons  coming  into  intimate  contact  with  such  patients  do  not 
become  infected.  The  Manchurian  experience  was  very  different 
(Manuad). 

1914.  During  the  plague  in  New  Orleans,  there  was" one  quarter 
where,  although  the  people  were  living  over  a  hotbed  of  infection,  no 
human  case  ever  occurred.  It  is  suggested  that  the  rat  population  was 
so  large  that  human  blood  did  not  present  any  temptation  to  the  rat 
fleas,  as  their  natural  hosts,  the  rats,  provided  ample  food  (Akin). 

1916.  There  was  plague  in  Bristol  during  July  in  humans  and 
rats.  Active  measures  eradicated  it.  Eight  out  of  seventy-four  rats 
caught  in  the  rag  factory  were  infected.  The  200  tons  of  rags  were 
then  destroyed  by  fire,  an  excellent  means  of  disinfection. 

This  is  the  twelfth  British  seaport  in  which  plague  has  occurred 
within  the  past  fifteen  years,  apart  from  a  sharp  pneumonic  attack  in 
Essex  about  ten  years  ago,  when  a  few  people  died  and  several  varieties 
of  animals  were  found  infected. 

History  shows  that  plague  is  wont  to  visit  a  country  once  in  300 
years;  the  last  epidemic  occurred  in  Britain  some  300  years  ago; 
another  is  due  now  (Cantlie). 

THE  CAUSATIVE  BACILLUS. 

The  B.  pestis  of  Kitasato  and  Jerson  is  found  in  the  initial 
cutaneous  vesicle,  buboes,  spleen,  blood  and  sputum  in  pneumonic 
cases. 

Monkeys,  rats,  guinea-pigs  have  been  successfully  inoculated  with 
typical  symptoms. 

Bovines  and  equines  give  local  reaction  only. 

Canines,  birds  and  reptiles  are  apparently  immune. 

Human  plague  is  an  offshoot  of  rat  plague. 

In  glucose  the  bacillus  forms  acid,  but  not  gas. 

In  lactose  it  gives  no  reaction. 

In  broth  with  cocoa-nut  oil  it  forms  flocculent  tapering  masses. 

Haffkine's  stalactite  growth,  verv  delicate  and  verv  readilv  broken 
off. 

The  pseudo-tuberculosis  bacillus  is  much  the  same;  inoculating 
guinea-pigs  is  required  to  differentiate  them ;  this  kills  in  three  weeks, 
the  plague  bacillus  in  three  days. 

B.  pestis  is  a  short,  oval  rod  with  rounded  ends,  capsulated  singly, 
but  in  cultures  they  grow  in  chains.  It  does  not  form  spores.  No 
true  motility.  Stains  readily  with  basic  aniline  stains.  Gram- 
negative;  grows  on  ordinary  media  at  body  heat;  flourishes  best  in 


ESSENTIALS    OF   TROPICAL   MEDICINE. 


Plague  bacilli.  Streak  preparation  from  spleen. 
Zeiss'  homog.  apochrom.  immersion  2  mm., 
apertnre  t.30,  compensation  oc.  4.  (Prepara- 
tion kindly  given  to  Dr.  Mott  by  Prof. 
Sticker,  Giessen). 


Bacilli  lepriE  in  the  nasal  secretion. 
Zeiss'  homog.  apochromat.  immersion 
2  mm.,  aperture  1.30.  (Preparation 
kindly  given  to  Dr.  Mott  by  Prof. 
Sticker,  Giessen.) 


Sputum  in  pneumonic  plague.  Plague  Ijacilli  in 
pure  culture.  Zeiss'  homog.  apochrom.  im- 
mersion 2  mm.,  aperture  1.30,  compensation 
oc.  4.  (Preparation  kindly  given  to  Dr.  Molt 
by  Prof.  Sticker.) 


Fau  Page  16S 


PLAGUE  169 

oxygen;  readily  killed  by  heat;  strong  resistance  against  cold.     Gains 
entrance  through  skin  abrasions,   more  often  flea  bites. 


Bacillus  pestis.     Smear  from  gland  juice,  1/12  oil  immersion. 


Bacillus  pestis.     Blood  film,  1/12  oil  immersion. 

PLAGUE  IN  RATS. 

Acute  and  chronic. 

In  the  acute  type  bubo  is  found   in   the   neck  or  axilku   in   85   per 
cent,  of  infected  rats.     There  is  subsequent  congestion,   purplish-red 


170  DISEASES   DUE   TO    BACTERIA 


'/ 


muscles,  waxy,  mottled,  or  finely  granular  liver,  haemorrhages,  and 
pleural  effusion.     Bacilli  in  bubo,  spleen  and  blood. 

In  the  chronic  Ivpe. — Encapsulated  caseous  foci,  abscesses  with 
bacilli  in  viscera,  but  it  does  not  spread  the  disease. 

Temperature  largelv  affects  the  prevalence  of  the  disease. 

In  Bombay,  fr(;m  December  to  May,  1,766  infected  rats  were  found 
in  one  week  during  which  a  search  was  made. 

In  the  cooler  season,  from  June  to  November,  they  are  not  so 
prevalent,  there  being  onh-  twentv  to  thirtv  found  during  the  week's 
search. 

All  rats  are  not  equally  infected.  Epimys  norvegicus  and  E.  rattus 
are  the  principal  species.  The  former  carries  twice  the  number  of 
fleas,  and  infection  is  more  rapidly  spread  by  it. 

E.  rattus  is  more  common  in  Bombay,  lives  in  houses,  less  seldom 
in  stables  and  outhouses.  Breeds  all  the  }'ear,  and  averages  a  family 
of  five. 

E.  norvegicus  li\'es  outside  houses  as  a  rule,  in  sewers,  drains  and 
stables.  It  is  ne\er  found  above  the  third  floor  of  a  house.  It  breeds 
all  the  year,  with  an  average  family  of  eight. 

One  species  infect  the  other  solely  by  the  flea.  Infected  urine, 
faeces,  air,  soil  and  food  will  not  give  plague  to  a  healthy  rat. 

The  flea  cannot  jump  more  than  4  inches.  If  rats  are  suspended 
above  this  height  from  infected  fleas  the\'  do  not  become  infected,  hence 
the  disease  is  not  air-borne. 

Infected  fleas  b}-  biting  healilu'  rals  produced  the  disease  in  55  per 
cent. 

The  blood  of  the  plague  rat  contains  100,000,000  bacteria  per  c.c. 

The  stomach  of  a  flea  holds  o'5  cm.  of  blood. 

Hence  a  gorged  flea  can  receive  5,000  bacilli. 

They  escape  soleh-  in  the  f^ces  of  the  flea.  Multiplication  of 
bacilli  takes  place  in  the  stomach  and  intestines  of  the  flea. 

Infected  fleas  transmit  disease  in  from  seven  to  fifteen  days. 

Take  spleen  smears  and  examine  for  B.  pestis. 

Do  a  Gram  stain  ;  if  positive,   the  organism   is  not  plague. 

Then  grow  cultures  and  inoculate  guinea-pigs. 

In  spleen  smears  there  may  be  clumps  of  bacteria  from  h'mphatics 
and  vessels.     Xo  other  bipolar  staining  organisms  give  this. 

Plague  in  domestic  animals  in  Bombay  either  does  not  occur  or 
h£is  little  significance. 

Some  Indian  rats  harbour  B.  pestis  without  svmptoms,  but  if 
injected  into  other  animals  i'.  I;ills  iliem. 

Young  rats  suckled  by  infected  mothers  are  not  infected  if  fleas 
are  absent. 


PLAGUE  171 

Cold  dead  rats  are  harmless,  as  the  flea  has  forsaken  them  for 
another  warm  host. 

The  Indian  Musk  Rat,  Crocidura  coerulea,  is  highly  resistant  to 
plague.  Only  one  rat  was  found  to  be  naturally  infected  witTi  plague 
by  the  Indian  Plague  Commission  (Kerandel). 

THE  CARRIER. 

The  flea  most  common  in  rats  is  Zenopsylla  cheopis,  but  others,  as 
Ceratophyllus  fasciatus  and  Pulex  irritans,  are  capable. 

Infection  by  the  flea  is  due  to  faecal  infection  of  the  proboscis  or 
of  the  wound  made  by  it,  which  transmits  the  bacilli  to  the  skin. 

Humans  are  infected  by  the  Z.  cheopis  from  the  Epimys  rattus. 

It  is  found  on  humans  after  cases  of  plague  in  man. 

Plague  infection  may  persist  in  fleas  for  one  or  two  months  in  the 
cool  weather,  and  subsequently  give  rise  to  an  epizootic  (Bacot). 

P.  vestimenti  is  capable  of  transmitting  plague  infection  also 
(Swellengrebel). 

Air,  however,  does  carry  the  bacillus  in  the  pneumonic  type  from 
the  sputum.  The  bubonic  or  septicaemia  is  not  spread  from  man  to 
man,  but  from  rats  to  man. 

Bugs  can  also  act  as  carriers,  C.  rotundatus. 

In  California  the  ground  squirrel,  Citellus  beecheyi,  is  subject  to 
plague,  and  its  common  flea,  C.  acutus,  spreads  it  from  one  to  another 
and  will  bite  man.  In  ^Manchuria  plague  started  among  those  who 
handled  the  Tarahagan  (Arctomys  bol^e) ;  no  infected  rats  were  found. 
The  epidemic  was  pneumonic. 

PATHOLOGY. 

The  site  of  the  flea  bite  is  sometimes  marked  by  a  vesicle,  the  con- 
tents containing  B.  pestis  in  large  numbers;  the  bacilli  travel  by  the 
lymphatics  to  the  nearest  glands ;  some  pass  to  the  thoracic  duct, 
thence  to  the  blood-stream,  and  so  cause  a  septicaemia.  More  often 
they  remain  and  multiply  in  the  lymph  glands  and  the  peripheral 
lymph  sinuses.  Their  toxins  cause  cell  degeneration,  periglandular 
serous  infiltration,  and  later,  degeneration  of  the  walls  of  blood-vessels 
and  haemorrhage.  The  l^^mphatics  are  matted  by  the  exudation, 
femoral,  inguinal,  axillary,  iliac  and  cervical.  The  groin  glands  are 
infected  most,  as  they  drain  the  largest  skin  area.  The  bacilli  may 
get  direct  to  the  blood-stream  by  injuring  the  veins  in  the  primary 
bubo.  Lymphatic  glands  also  become  affected  after  the  infection  has 
become  a  septicemia.  Also  the  lung  causing  bronchitis  and  secondary 
pneumonia,   spleen,   liver,   kidneys,   skin  and  other  organs. 

The  sputum  and  saliva  can  be  infected  forty-eight  days  after  the 


172  DISEASES   DUE    TO    /BACTERIA 

temperature  is  normal,  and  abscesses  may  contain  bacilli  ten  weeks 
after. 

The  chemical  pathology  is  unknown. 

In  epidemic  pneumonic  plague  the  primary  infection  is  in  the 
bronchi  from  inhalation,  setting  up  peribronchial  inflammation. 

Lobular  and  lobar  pneumonia  develop  quickly,  and  then  a  septi- 
caemia. 

There  is  no  evidence  that  it  has  ever  started  in  the  great  intestinal 
tract,  though  many  bacilli  must  have  been  swallowed. 

P.M. 

Post-mortem  rise  of  temperature  is  not  uncommon.  Decomposition 
early. 

(i)  The  skin  about  buboes  shows  haemorrhage  resulting  from 
toxins  acting  on  endothelial  cells  of  vessels.  The  ha^mor- 
rhages  are  petechial  or  diffuse  and  contain  bacilli.  \'esicles, 
pustules,  so-called  carbuncles  may  be  seen. 

(2)  Glands. — The   primary   bubo   shows   periglandular    infiltration. 

Glands  matted,  greyish,  soft  centre,  numerous  ha^morrhagic 
spots  or  large  haemorrhages. 

The  secondary  buboes  (those  infected  by  drawing  from  the 
primary  gland)  are  degenerate  glands,  no  oedema,  endo-  and 
peri-glandular  haemorrhages. 

The  tertiary  buboes  (those  infected  after  it  has  become  a 
septicaemia)  are  hard,  hyper^mic  and  h^emorrhagic. 

(3)  Muscles,  especiallv  those  of  abdominal  walls,  are  ha?morrhagic. 

(4)  Viscera. — Spleen  enlarged  two  to  three  times  the  normal  size, 

congested,  hjemorrhagic,  bacilli  very  numerous,  necrotic 
areas,  dotted  with  pin  points. 

Liver  enlarged,  somewhat  mottled,  haemorrhagic.  cloudy 
swelling,   fatty  degeneration. 

Lungs,  some  bronchitis,  and  often  patches  of  secondary 
broncho-pneumonia. 

Efi^usion  into  pleural  sacs  common  with  hccmorrliage. 
R.     heart     dilated,     fatty     degeneration,     cloudy     swelling, 
haemorrhage. 

Stomach    hypera^mic,     haemorrhage,     solitary    glands    and 
Fever's  patches  swollen,  mesenteric  glands  markedly  so. 
For  sections  stain   \\ith  strong  carbol   thionin,   stop  its  action   with 
oil  of  cloves  and  remove  the  stain  therewith. 
SYMPTOMATOLOGY. 

Incubation. — Two  to  ten  days,  average  three  days. 
Frodromal      symptoms. — General       malaise,       headache,       gastro- 
intestinal   disturbance,    glandular   pain,    chilliness,    giddiness,    mental 
dulness. 


PLAGUE  173 

Onset.— Sudden,  temperature  on  third  day  rises  to  i03°-i04°  F.,  and 
falls  on  the  sixth  or  seventh  day  (remember  pneumonia).  Pulse  130, 
respirations  30-45.  Marked  prostration,  vomiting,  diarrhoea,  general 
bodv  pains,  rigor  and  staggering  gait.  In  a  few  hours  after  the  onset 
eyes  become  bloodshot,  nostrils  dilated,  and  temperature  very  irregular; 
if  recovery  it  may  fall  by  lysis,  or  if  no  recovery  it  falls  rapidly  to  sub- 
normal, and  rises  rapidly  to  107°  F.,  and  death  supervenes.  Thirst  is 
marked.  Tongue  furred  at  first,  later  sordes  on  tongue,  teeth,  and 
lips. 

Abdomen  not  tender  imless  there  are  enlarged  abdominal  glands. 

Spleen  always  enlarged.     Liver  often. 

Cardiac  dilatation  important. 

Pulse  may  rise  to  180  and  become  thready. 

Coagulation  of  blood  diminished.     Bacilli  can  be  grown  from  the 
blood    in    manv   of   the   cases.      Red   cells   and    lib.    increased,   leuco- 


Inguinal  plague  bubo.     (From  Prolessor  Simpson's  collection.) 

cytosis  is  marked  90,000 — 100,000,  but  leucopa^nia  mav  ensue  in 
septicemic  foi'ms. 

Breathing  rapid,  B.S.  harsh  with  moist  rales,  signs  of  lobar 
pneumonia  may  occur,  sputum  is  then  ha?morrhagic  and  full  of  bacilli. 

Buboes,  seen  in  groin,  axillae  and  neck,  are  painful.  The  legs  mav 
be  drawn  up,  or  the  head  bent  over  because  of  them,  when  seen  in  the 
first  twenty-four  hours.     These  glands  may  resolve  or  suppurate. 

Skin  hot  and  dry,  with  vesicles,  pustules,  necrotic  areas,  petechia,, 
ecchymosis,  epistaxis,   hc-ematemesis,   mal^ena,   haematuria. 

Urine  diminished.     Specific  gravity  high;  bacilli  may  be  found. 

Anuria  usually  before  death. 

Pregnant  women  alM^ays  abort. 

Weakness,  wild  delirium,  coma,  death  third  to  fifth  dav. 

If  recovery,  temperature  resolves  by  lysis,  pulse  rate  is  diminished 
and  convalescence  begins.  Death  may  still  ensue  from  cardiac  failure, 
suppuration,  septic  infection,  or  secondary  haemorrhage. 


174  DISEASES   DUE   TO    BACTERIA 

VARIETIES. 

(i)  Ambulatory  Type,  the  mildest  form. — The  symptoms  can  be 
looked  upon  as  the  prodromal  symptoms,  aggravated  some- 
what. 

(2)  Bubonic  Type. — The  bubo  is  usually  in  the  groin.     The  fever 

maximum  is  reached  on  the  fourth  or  fifth  day,  and  lasts  till 
the  seventh  or  tenth  day,  falling  by  lysis,  and  rising  again  if 
suppuration  sets  in. 

(3)  Septica?mic    Tvpe.       Onset    sudden,     temperature    high,    very 

rapid  pulse,  marked  prostration,  severe  vomiting,  diarrhoea, 
hc-emorrhage,  death  in  one  to  three  days. 

Children    may   be   playing    in    the   street    in    the    morning, 
haemorrhage  in  the  afternoon,  and  dead  next  morning. 

(4)  Pneumonic  Type. 

(i)  Primary  pneumonia. 

No  prodromata ;  incubation  two  to  five  days. 

Cough    and    dyspnoea    within     twenty-four    hours;    bloody 
expectoration  with  bacteria  second  to  third  day. 

Conjunctiva  injected,   respiration  rapid,   dyspnoea,   cyanosis. 

Spleen  not  usually  palpable. 

Very  fatal. 
(2)  Secondary  pneumonia  (after  buboes). 

As  general  symptoms. 

MORTALITY  varies.     Apart  from  mild  attacks  it  is  60-95  P^^'  cent. 
Chinese  93*4  per  cent. 
Japanese  60  per  cent. 
European  i8"2  per  cent. 

Of  known  and  controllable  cases  in  hospitals,  jails,  &c.,  35-45  per 
cent. 

TREATMENT. 

Bed,  good  nursing,  fresh  air. 
Fever  with  sponging  and  cold  applications. 
Heart  by  digitalis,  struphanthus  and  strychnine. 
Restlessness;  opiates,   chloral,   potassium  bromide. 
Haemorrhage;  calcium  chloride  or  lactate. 
Constipation  ;  calomel  and  saline. 
Pneumonia;  the  ordinary  treatment. 
Kidneys,  much  fluid  to  keep  them  flushed. 
Diet;  broths,  milk,  stimulants  usually. 
Diarrhoea;  ice  pills  and  morphia,  hyclroc}'anic  acid,  salol. 
Buboes.     Glycerine  and  belladonna,  when  suppurating  incise  and 
drain. 


PLAGUE  17s 

PUBLIC  PROPHYLAXIS. 

Institute  a  sanitary  service  in  an  infected  country  with  collectors, 
bacteriologists,  &c. 

Port  sanitary  authority  to  investigate  and  disinfect  ships. 

Isolate  as  far  as  possible. 

Quarantine  five  davs. 

Medical  inspection  of  passengers  by  rail,  road  and  river. 

Disinfection  of  clothing,  and  merchandise  by  Clayton's  method. 

Rats  to  be  caught  and  examined. 

Recognition  of  early  cases,   investigations  oi  sudden  deaths. 

House  to  house  visitation  by  M.  O. 

\'illage  houses  burned.  Kill  rats  by  SO.,  SO^,  Danyz's  virus  on 
bread;  encourage  cats.  Work  from  the  outside  of  a  circle.  Cover 
hands  with  oil  of  aniseed  as  rats  know  if  humans  have  touched  food 
set  to  catch  them.  Phosphorus  paste,  with  glucose  to  prevent  com- 
bustion, with  lard  as  a  basis.  Traps;  two  to  100  of  the  population  (in 
proportion). 

Prophylaxis  as  suggested  by  Haffkine. 

(i)  Discovery  and  notification  of  persons  attacked  with  disease. 

(2)  Isolation  of  those  attacked. 

(3)  Certain  precautions  with  regard  to  the  disposal  of  the  dead. 

(4)  Segregation  of  those  who  have  come  in  contact  with  the  sick  or 
dead. 

(5)  Institution  of  cordons  round  infected  areas,  or 

(6)  Placing  in  quarantine  arrivals  from  infected  places.     Detaining 
the  sick  and  suspected,   liberating  the   remainder. 

(7)  Or  examine  travellers,  isolate  sick  and  suspected  and  let  others 
free  under  surveillance. 

These  are  always  difficult,  often  impracticable,  and  achieve  little. 

Second  method.      Within  the  affected  area. 

Destroy  or  disinfect  houses,  furniture,  clothing,  bedding,  carriages, 

goods,   warehouses,   grains  and  other  stores,   garbage,   drains  and 

streets. 

Outside  the  infected  area. 

Refusal  to  admit  carts,  trains  and  ships  with  goods  from 
infected  places;  or  refuse  to  admit  only  certain  goods;  or  inspec- 
tion of  trains,  carts,  ships  with  measures  by  which  these  and 
the  goods  they  convey,  as  well  as  the  belongings  of  travellers, 
are  rendered  harmless. 

The  expense  and  difficulty  of  such  is  enormous. 

Third  method. 

(i)  Destruction  and  keeping  away  of  rats  by  poisoning,   trapping, 
tar  and  sulphuric  acid  mixture,  or  by  the  domestic  cat. 


i;6  DISEASES   DUE   TO    BACTERIA 

(2)  Structural  alteralions  of  dwellings  and  stores,  demolition  of  in- 
sanitary buildings,  prompt  disposal  of  garbage,  periodical  inspec- 
tion of  stores  having  drainage  witii  view  of  keeping  down  rats. 

(3)  Destruction  and  dispersion  of  fleas  by  petroleum,  &c. 

(4)  Fumigation  of  houses  against  rats  and  fleas. 

(5)  Obligation  of  ships  from  infected  regions  to  anchor  away  from 
the  shore. 

(6)  Provide  mechanical  means  for  preventing  rats  from  landing 
along  mooring  cables  and  gangways. 

(7)  Fumigation  of  ships  arriving  with  plague  patients,  plague  rats 
or  suspected  bedding. 

Such  would  cause  a  dislocation  of  trafific  and  an  outcry,  formidable 
to  face;  the  result  is  that  plague  is  still  spread. 

If  men  are  honest,  rals  are  not  and  regulations  are  broken  down. 

PRIVATE  PROPHYLAXIS. 

Yersin's  serum,  from  a  horse  inoculated  with  fresh  agar  cultures; 
give  20-200  c.c.  intravenously  and  subcutaneously  near  the  buboes. 
There  may  be  urticaria  and  pleurodynia  for  three  days. 

For  Yersin's  serum  to  have  anv  appreciable  effect  on  the  course  of. 
the  disease,  the  first  injection  must  be  given  wuthin  forty-eight  hours 
from  the  appearance  of  symptoms. 

Lustig  and  Galeottis'  serum,  from  a  horse  injected  with  vaccine. 
Both  these  are  supposed  to  stimulate  phagocytosis  and  are  not  bacteri- 
cidal. 

Lustig  and  Galeottis'  vaccine ;  shake  agar  cultures  with  i  per  cent. 
of  caustic  potash,  and  after  two  hours  add  o'5  per  cent,  acetic  acid,  and 
thus  obtain  a  precipitate  of  nucleo-proteids. 

Subcutaneous  or  intramuscular  2-3  milligrammes. 

Haffkinc's  Prophylactic  Vaccine. — Grow  bacteria  on  broth  and 
butter  fat  4  to  6  weeks;  stalactite  growths  form. 

Sterilize  at  65°-70°  C.  for  one  hour. 

Decant  into  bottles  with  a  little  carbolic  acid. 

Dose. — 3  c.c.  for  an  adult  man.     Subcutaneously  about  deltoid. 

There  is  a  local  and  general  reaction  arising  in  a  few  hours  and 
disappearing  in  i  to  3  days.     Reaction  may  be  severe  or  mild. 

This  protects  from  2  to  12  months  and  is  used  much  in  India.  Good 
results. 

It  requires  10  to  14  days  to  produce  suflRcient  immunity;  during  that 
time  resistance  is  diminished.  In  a  Punjab  experiment  in  1903  the 
mortality  was  60  per  cent.;  in  the  inoculated  it  was  2^^  per  cent. 

ATTENUATED   CULTURES. 

Strong. — Intramuscular  injection  of  one  whole  twenty-four  hours 
agar  slant  of  living  virulent  culture.     The  reaction  is  not  excessive. 


PLAGUE— NOTES    ON   FLEAS  \77 

Opsonic  index  rises  markedly  ten  days  later. 
Guinea-pigs,  mortality  66-6  per  cent.;  inoculated  iG'G  per  cent. 
Klein's  protective  inoculoiion   prepared   from   the  organs  of  dead 
imimals  of  plague;  he  says  :  — 

(i)  It  requires  ten  to  twelve  days  to  prepare  it;  Haffkine's  requires 
four  to  six  weeks. 

(2)  A  large  amount  can  be  prepared  of  uniform  strength. 

(3)  Its  efficacy  is  easily  standardized  by  injection  into  the  rat. 

(4)  Being  dry  and  sterile  it  can  be  preserved  without  antiseptic  and 

kept  unaltered. 

(5)  That  its  injection  into  the  rat  protects  certainly  many  weeks. 

(6)  Cost  of  its  preparation  is  much  less  than  Haffkine's.  This 
has  not  yet  been  tried  on  man. 

Masks  of  flannel  cloth  to  cover  the  head  tied  about  neck  with 
window  of  sheet  celloidin  are  advisable. 

NOTES  ON  FLEAS.     (Order  Siphonaptera.) 

Fleas  are  active  parasites  of  mammals  and  birds.      They  usually 
have  a  preference  for  one  host,  and  attack  others  with  some  reluctance. 
They  act  as  carriers  or  necessary  intermediaries,  e.g. — 
(i)  The    common    dog    flea    and    the    common    European    rat    flea 

harbour  the  cysticercus  of  certain  tapeworms  of  their  respective 

hosts. 

(2)  The  trypanosome  of  the  rat  passes  through  certain  stages  of  its 

developmental  cycle  in  the  European  rat  flea. 

(3)  They  are  carriers  of  the  plague  bacillus  among  rats  and  other 

rodents,  and  from  these  to  man. 

Pulex  (Xenopsylla)  cheopis  most  commonly  infests  house  rats  in  the 
tropics. 

The  Pulex  irritans  (the  human  ilea)  and  others  are  capable  of 
carrying  the  plague  bacillus. 

EXTERNAL  APPEARANCE. 

Fleas  are  laterally  compressed,  wingless  insects,  with  two  piercing, 
sucking  mouth  parts.  The  head  is  broadly  articulated  to  the  thorax; 
all  three  segments  of  the  thorax  are  distinctly  independent.  Eyes  may 
or  may  not  be  present ;  when  present  they  are  simple  and  not  com- 
pound as  in  the  house  fly.  A  comb  of  teeth  is  found  on  the  edge  of 
the  cheek  or  on  the  lower  edge  of  the  head  in  most  species. 

The  antennas,  two  basal  segments  and  a  club  with  nine  rings,  lie 

behind  and  above  the  eyes.     Bristles  are  seen  irregularly  placed  about 

the  head  and   thorax.     They   have  a  pair  of   longitudinally  grooved, 

serrated,  needle-like  mandibles,  which  form  an  efferent  tube  for  saliva, 

12 


178 


DISEASES   DUE    TO    BACTERIA 


and  an  unpaired  bristle  which,  opposing-  iisdf  lo  these,  forms  am 
afferent  tube  for  sucking  blood. 

The  three  pairs  of  legs  with  their  paired  claws  are  long  and  strong. 

The  abdomen  has  ten  segments;  the  last  three  arc  modified  for 
sexual  purposes. 

The  male  has  on  the  ninth  segment  large  claspers  and  a  large 
complex  penis. 


Pttlex  itf-ilans.      14/1. 


Larva  of  flea.     Enlarged. 
(After  Railliet.) 


Pulex  serraticeps.     22/1. 

ALIMENTARY  TRACT. 

In  the  head  is  an  elastic  pharynx  acting  like  a  suction  pump ;  its 
cavity,  when  expanded  by  the  contraction  of  certain  muscles,  forms  a 
vacuum. 

The  stomach  is  very  distensible,  the  rectum  is  large.  They  carry- 
two  pairs  of  salivary  glands. 

REPRODUCTION. 

The  eggs  are  large,  dropped  casually  in  places  where  domestic 
animals  sleep,  hatching  in  two  to  fourteen  days  according  to  tempera- 


LEPROSY  179 

lure.  The  larvcB  are  active,  white,  hairy  maggots  with  a  head  and 
thirteen  segments,  the  last  carrying  a  pair  of  hooks.  They  eat  organic 
matter  from  dust,  and  spin  a  cocoon  in  two  weeks  or  longer,  in  which 
they  pupate. 

The  cocoon  coated  with  dust  contains  a  hump-backed  pupa  which 
can  develop  in  two  weeks. 

There  are  two  main  families  :  — 

Pulicidce,  which  contains  Pulex  irritans,  the  common  human  flea, 
and  Xenopsylla  cheopis,  the  tropical  rat  flea. 

SarcopsyllidcB,  which  contain  the  Dermatophilus  penetrans  or  jigger. 

Indigenous  to  South  America,  but  carried  to  the  Gold  Coast,  East 
Africa,   and  Bombay. 

It  flourishes  best  in  sandy  places.  It  attacks  man  and  other 
animals,  including  the  pig.  Both  sexes  suck  blood,  but  the  pregnant 
female  embeds  herself  in  the  skin,  often  under  the  bed  of  a  toe-nail, 
and  in  this  inflamed  pocket  lays  her  eggs.  Pain  and  inflammation 
result,  leading  to  indolent  ulceration  and  even  gangrene. 

TO  DESTROY  FLEAS. 

Close  the  room,  spray  completely  with  5  per  cent,  solution  of 
formalin,  or  sprinkle  copiously  with  powdered  naphthalin,  and  leave 
closed  for  two  days. 

Then  burn  all  sweepings.     Wash  floor  with  formalin  or  lysol. 

Ants  eat  the  larva5  and  pup^e. 

For  personal  use,  use  quinine,  quassia,  sulphur,  petroleum,  which 
are  repellent  to  fleas. 

LEPROSY. 
DEFINITION. 

A  chronic  infective  disease  caused  by  Hansen's  bacillus,  with 
characteristic  lesions  of  the  skin,  mucosae  and  nerves. 

HISTORY. 

Perhaps  brought  from  Egypt  to  Italy  by  Pompey's  troops,  dis- 
seminated throughout  Europe  by  the  Roman  legions.  The  returning 
Crusaders  (1098)  increased  it. 

Lepers  were  isolated  in  Europe  in  the  13th  century.  Thev  were 
compelled  to  wear  a  special  dress,  to  use  clappers  when  on  the  roads, 
and  to  point  with  a  stick  to  articles  in  the  market  which  they  wished 
to  buy.  They  were  forbidden  to  drink  from  the  public  fountains,  or 
eat  with  healthy  people.  They  were  officially  dead,  and  the  burial 
service  was  read  over  them  as  soon  as  they  were  diagnosed  as  lepers. 
Lepers  gradually  diminished  from  this  time  onwards. 


i8o  DISEASES   DUE   TO    BACTERIA 

The  Spaniards  perhaps  took  the  disease  to  America. 

In  the  i6th  century  the  imported  West  African  slaves  carried  it  to 
the  West  Indies,  the  Chinese  to  the  Sandwich  Islands,  Colombia,  Ntnv 
Zealand,  &c. 

It  was  carried  to  South  Africa  by  the  Dutch  from  Java  in  1756,  and 
by  the  East  Indian  troops  in  the  19th  century, 

Hansen  discovered  a  bacillus  in  187 1,  and  associated  it  with  the 
causation  of  the  lepra  lesion  in  1877. 

The  method  of  infection  is  unknown. 

DISTRIBUTION. 

Present  in  Ireland  in  432  a.d.,  and  in  England  in  950  a.d. 

The  last  British  leper  died  in  the  Shetland  Isles  in  1798. 

Present  in  Iceland,  Spain,  Italy,  Balkans,  Crete,  Cyprus,  Norway, 
Sweden  and  Greece.  Common  throughout  Asia,  Ceylon,  India, 
Australia  (Queensland  and  New  South  Wales).  The  Sandwich 
Islands  in  1891  had  one  in  thirty  infected,  1,500  in  all.  It  is  present 
in  the  United  States,  Mexico,  Central  America,  Colombia,  West 
Indies,  Venezuela,  Guiana,  Brazil,  Africa  and  Egypt,  which  was 
probably  its  original  home. 

In  India,  in  1891,  there  was  one  leper  in  every  2,000  people,  105,000 
in  all. 

In  New  Caledonia  there  w^ere  no  lepers  in  1865.  A  Chinese  known 
leper  w^ent  there,  and  later  in  1888  there  were  4,000  lepers. 

In  the  13th  century  there  were  19,000  leper  houses  in  Christendom, 
according  to  the  Benedictine  monk,   Mathew  Paris. 

In  France  there  were  2,000  and  in  England  95,  besides  smaller  pest 
houses  in  Ireland  and  Scotland  (Sir  James  Simpson). 

1890,  there  were  1,100  lepers  in  Norway. 

1906,  there  were  only  500  there. 

1915,  there  were  40  lepers  in  the  United  Kingdom  (Dr.  George 
Pernet). 

THE  BACILLUS. 

Hansen's  Bacillus  laprse  resembles  T.B.  in  size,  shape,  and  stain- 
ing reaction.  Stain  as  for  T.B.,  but  use  a  weaker  solution  of  H2SO4, 
5  per  cent.,  in  decolorizing.  For  films  and  thin  sections  use  the 
H2SO4  solution  for  fifteen  seconds. 

It  has  been  found  in  nasal  secretion,  tears,  saliva,  sputum,  milk, 
semen,  urethral  and  vaginal  secretions,  faeces,  skin  scales,  extra-  and 
intra-cellular  in  liver,  spleen,  glands,  and  breaking-down  tubercles. 

It  has  not  been  found  in  earth,  dust,  air,  water  or  food. 

It  is  doubtful  if  it  has  ever  been  cultivated. 

It  is  acid-fast,  but  stains  more  readily  than  T.B.  with  cold,  weak 


LEPROSY  i8i 

carbol  fuchsin,  and  is  more  readily  decolorized,  is  motile,  and  easily 
obtained.     It  is  numerous  in  nodular  and  scarce  in  anaesthetic  forms. 

Not  found  in  muscle,  bone  or  cartilage. 

Apes  have  been  inoculated  (Nicolli). 

HOW  SPREAD. 

It  cannot  arise  de  novo,  hence  it  must  be  carried  by  one  or  more  of 
the  following:  air,  soil,  water,  plants,  insects,  beasts,  food,  or  man. 
It  has  only  been  found  in  human  tissue. 

Perhaps  contagious.  Benson,  an  Irishman,  acquired  leprosy  in 
the  West  Indies,  and  returned  to  Ireland.  He  died  from  it  in  eleven 
months.  His  brother  had  lived  and  slept  with  him,  and  later  wore 
his  clothes;  in  four  years  he,  too,  was  a  typical  leper.  He  had  never 
been  out  of  the  British  Isles. 

Note  its  spread  throughout  Europe,  its  rapid  spread  in  the  Sand- 
wich Islands.  In  twenty  years  800  lepers  were  isolated,  and  one-tenth 
of  the  population  was  affected. 

Father  Damien  went  as  a  missionary  from  Belgium  to  the  Sandwich 
Isles  in  1873,  and  died  of  leprosy  in  1889. 

Ten  per  cent,  of  the  children  of  lepers  become  lepers. 

The  success  after  isolation  supports  the  contagion  theory. 

Against  contagion. — The  attendants  of  Hendela  Leper  Asylum  of 
Ceylon  have  not  contracted  it. 

There  is  no  proof  that  sexual  intercourse  spreads  it. 

A  child  has  never  been  born  a  leper. 

It  is  present  among  people  who  do  not  eat  fish. 

All  possible  means  of  spread  have  their  supporters. 

It  may  in  all  possibility  be  spread  by  insects,    ?  bed  bug. 

As  lepers  are  sterile  early,  if  it  is  hereditary,  leprosy  would  soon 
die  out. 

The  fish  theory  is  not  now  held  by  many.  If  it  is  a  good  medium 
it  should  be  good  for  cultivating  the  bacilli,  but  it  is  not.  In  Abyssinia 
there  are  8,000  lepers  who  rarely,  if  ever,  eat  fish. 

PATHOLOGY. 

How  and  where  it  enters  the  body  is  unknown.  Perhaps  by  the 
nasal  mucous  membrane  (McLeod). 

They  form  colonies  in  the  lymph  spaces,  and  later  are  disseminated 
by  blood  and  lymph  vessels. 

Few  diseases  show  so  many  bacilli. 

Plasma  cells  surround  capillary  vessels  and  lymph  capillaries, 
which  are  much  dilated. 

The  Leproma. — Large  lepra  cells  containing  masses  of  bacilli. 


i82  DISEASES   DUE   TO    BACTERIA 

A  smooth  white  and  brown  ghstening  nodule,  hard  from  fibrosis 
or  soft  from  degeneration,  well  supplied  with  vessels.  No  true  giant 
cells.  The  bacilli  do  not  invade  the  surface  epithelium,  nor  the  cutis 
beneath  this,  nor  sweat  glands,  nor  hair  sheaths  superficial  to  the  open- 
ing of  the  sebaceous  glands. 

In  section  one  sees  the  epithelium  normal,  but  with  no  inter- 
papillary  processes. 

Then  larger  cells  of  connective  tissue  free  from  bacilli. 

Then  lepra  cells,  plasma  cells,  connective  tissue  cells,  vessels  with 
little  connective  tissue,  vessels  much  thickened,  sometimes  with  the 
lumen  obliterated,  and  then  lymph  spaces  dilated  and  filled  with  bacilli 
surrounded  by  mucus  forming  the  "globi." 

Beneath  this  is  normal  connective  tissue. 

The  leproma  may  break  down  the  skin  and  ulcerate,  disseminating 
the  bacilli  in  the  discharge. 

Bacilli  may  enter  the  nerves,  causing  hyperplasia  of  the  coats, 
forming  thickened  leproma  about  the  vasa  nervorum,  and  later,  in  the 
perineurium  and  endoneurium. 

These  press  on  the  nerve  fibres,  causing  degeneration  of  the 
neurilemma,  and  destruction  of  the  nerve  fibres,  which  become  con- 
verted into  connective  tissue. 

The  bacilli  may  attack  the  anterior  cornua  of  spinal  cord. 

Any  organ  may  be  the  site  of  leprotic  lesions. 

P.M. 

Skin  tubercles  may  or  may  not  be  ulcerated.  Pigmented  patches 
may  be  seen.  Liver  enlarged,  bacilli  infiltrate  portal  systems,  seen  as 
yellow  dots.  Spleen  also.  Bacilli  are  never  found  in  the  liver  cells 
themselves. 

Ovaries  and  testes  may  show  infiltration  and  fibrosis  of  interstitial 
tissue,  which  destroys  sexual  elements  and  causes  the  sterility  so 
marked  in  lepers. 

The  lymphatic  glands  are  infiltrated  and  enlarged. 

The  ulnar,  median,  peroneal,  post-tibial  and  great  auricular  nerves 
are  affected  most. 

Posterior  sclerosis  of  the  cord  and  meningitis  are  not  uncommon. 

Trophic  changes  in  joints  and  perforating  ulcers. 

Lungs  may  be  affected,  more  solid  than  in  T.B.,  caseate  less 
frequently,  less  prone  to  be  destroyed. 

SYMPTOMATOLOGY. 

Incubation  not  known  ;  perhaps  two  or  three  years  at  least. 
Begins  usually  in  subjects  from  lo  to  13  years  of  age,  rarely  after  40. 
Sometimes  children  are  lepers  first  and  parents  later. 


LF.PROSy 


183 


Blotches  and  patches  for  years  may  have  been  disregarded. 
Epistaxis,    frontal   headache,    intermittent   fever,    numbness,    abnor- 
mal, local  or  general  sweating  without  sufficient  cause. 


(l  and  3)  Hindoo  girls  :   (2)  Hindoo  woman  with  nodular  leprosy. 

These  may  be  seen  at  intervals  for  several  years.  The  point  of 
"entry  is  perhaps  the  nose.  128  out  of  153  lepers  had  the  bacilli  in  the 
nose  first.  After  general  dissemination  the  bacilli  settle  in  the  skiu 
and  nerves,  giving  us  the  tubercular,  anaesthetic  or  mixed  leprosv. 


1 84 


DISEASES   DUE   TO    BACTERIA 


(i)  Tubercular   Variety. 

A  severe  fever  accompanied  by  an  erythematous,  diffuse  or  macular 
eruption  on  the  face  and  Hmbs.  This  may  subside  or  macules  may 
develop  into  tubercles. 

This  is  repeated,  glands  enlarge,  fever  may  sometimes  be  absents 

Tubercles  and  nodules  come  first,  usually  on  the  face  and  forehead, 
cheeks,  aU'E  of  nose,  lobules  or  ears,  lips  and  chin.  They  soon  alter 
the  appearance  of  the  patient.  The  tubercles  are  the  size  of  split  peas, 
dirty  pink  or  dark  brown,  resembling  sebaceous  follicles.  Beard, 
moustache,  and  eyebrows  drop  out  early.  Complete  madarosis  is  not 
uncommon. 

Paralysis  of  the   frontalis  muscles  is  sometimes   seen. 


Deformities  in  anresthetic  leprosy. 


Tubercular  leprosy.     Marked  case. 


Abotit  the  eye. 

Eyelids  show  diffuse  or  nodular  lepromata,  these  mav  ulcerate  and 
destroy  the  eyelids. 

Conjunctiva;  may  become  infiltrated,  ectropion,  zerophthalmia. 

Episclera  infiltrated  external  to  corneo-sclerotic  junction. 

Small  spots  on  cornea —  "  keratitis  punctata  leprosa." 

Uveal  tract  is  infiltrated,  anterior  and  posterior  iritis  may  occur; 
nodules  may  form   in  the  ciliary  body  or  near  the  canal  of  Fontana, 
causing  irido-cyclitis,  or  irido-choroiditis. 

About  the  nose. 

Nasal  mucosa  shows  nodules,  occlusion  may  ensue  with  ulceration 
and  destruction  of  the  nose,  disfiguration  from  cicatrization.  Sense 
of  smell  is  lost. 


LEPROSY 


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i86  DISEASES   DUE   TO    BACTERIA 

About  the  mouth. 

Tongue,  mouth  and  pharynx  may  be  affected,  mastication  and 
deglutition  difficult;  when  in  larynx  the  voice  becomes  raucous, 
respiration  impeded.  Lips  become  paralysed,  saliva  dribbles,  gums 
retract,  teeth  fall  out,  taste  is  lost. 

About  the  skin. 
A  goat-like  odour.     Tubercles  on  hands,  arms  and  legs  which  may 
ulcerate. 

Submaxillary,  cervical  and  femoral  glands  may  be  enlarged  and 
may  suppurate. 

Testes  fibrous,  menstruation  irregular  and  may  cease. 

Fingers  and  toes  atrophy,  ulcerate,  drop  off,  then  phalanges  and 
metacarpals  likewise. 

Blood. 

Nil  diagnostic.     No  marked  or  consistent  changes. 

Nerves  may  be  attacked  and  add  their  corresponding  signs  and 
symptoms. 

Ulcerations  may  cicatrize  and  produce  deformities  or  suppurate  and 
produce  amyloidosis  or  become  phaged^enic  causing  septic  poisoning, 
gangrene  of  fingers  or  toes.     Nephritis  is  common. 

(2)  ANAESTHETIC  VARIETY. 

Infiltration  is  chiefly  in  the  nerves;  fibres  irritated  at  first,  then 
destroyed.  Shooting  pains  of  ulnar  and  peroneal.  There  are  sensory 
disturbances  as  burning,  numbness,  formication;  vasomotor  disturb- 
ances as  flushings,  glossy  skin;  and  motor  disturbances  as  facial 
twitchings  of  muscles. 

A  macular  eruption,  flat  red  spots  appear  without  any  general 
disturbances,  some  being  pigmented.  Spots  increase  in  size,  centres 
become  pale,  the  peripheries  usually  are  raised,  marked  with  papules 
t)r  vesicles,  or  dry  whitish  scales.  Such  areas  may  coalesce  forming 
patches  half  an  inch  to  six  inches  in  diameter. 

Within  these,  the  skin  is  anaesthetic,  hairs  fall  out,  does  not  sweat. 

Wrinkles  and  scales  appear. 

Hypersesthetic  outer  border  may  look  like  a  big  ringworm. 

The  disease  may  become  quiescent  and  fade  at  any  time. 

Nerves. — Ulnar  nerve  thickened,  felt  behind  internal  condyle,  great 
auricular  felt  over  sternomastoid.     Peroneal  below  head  and  fibula,  &c. 

With  destruction  of  nerve,  hyperaesthesia  ends  and  anaesthesia 
begins. 

Noticed  first  usually  along  ulnar  side  of  hand  and  f<:)rearm. 

It  may  be  patchy  or  in  distribution  of  nerve. 


LEPROSY 


187 


Paralyses  of  interossei  of  hands  (main-en-griffe),  thenar  and  liypo- 
thenar  eminences,  also  of  forearm  causing  "  drop  wrist." 

Plantar  muscles  of  toes,  peronei,  extensors — "drop  foot  "  with  an 
internal  twist. 

Reflexes  increased,  later  diminished,  muscles  waste,  R.D.  distinct. 

Trophic  lesions,  whitlows  on  fingers  occur,  necrosis  of  phalanges, 
or  simple  absorption  of  bone,  the  nail  persisting. 


Maculae  in  anaesthetic  leprosy. 

Also  on  lower  extremities  there  are  bullae  varying  in  size  from  a 
pea  to  that  of  an  Ggg.     Perforating  ulcers. 

Fissures  in  digits  of  hands,  toes,  dry  gangrene,  or  bones  of  fingers 
may  soften  and  become  osteomalacic. 

Eye  is  more  often  damaged  by  secondary  infection,  the  result  of  the 
absence  of  lachrymal  secretion  and  lagophthalmus. 

Secretion  of  tears  is  diminished,  xerophthalmia  with  posterior  or 
total  symblepharon,  while  desiccation  and  destruction  of  cornea  may 


i88  DISEASES   DUE   TO    BACTERIA 

result.     Secondary  infection  leads  to  keratitis,  onyx,  hypopyon,  iritis, 
irido-cyclitis  and  total  destruction. 
Sterility  is  not  so  frequent. 

(3)  MIXED  VARIETY. 

Some  tubercular  cases  develop  nerve  leprosy. 
Some  nerve  cases  develop  tubercular  leprosy. 
Some  advance  equally. 
Diagnosis. 

Bacilli  always  present  in  the  nodular  variety.  In  early  cases  look 
in  the  nasal  secretions. 

in  the  anaesthetic  form  the  bacilli  are  more  difficult  to  find. 

PROGNOSIS. 

Cure  is  exceptional.     Periods  of  apparent  cessation  not  uncommon. 
Tubei'cular  or  mixed,  2  to  12  years'  duration.  • 
Anaesthetic  form,  6  to  20  years'  duration. 

Intercurrent  disease  often  kills.  Death  is  seldom  from  the  disease 
itself. 

TREATMENT. 

None  specific.  Fresh  air,  good  food,  isolation,  removal  of  child- 
ren, light  work,  amusement,  rural  colonies. 

It  is  a  wise  procedure  to  emigrate  the  children  of  lepers;  160  of  such 
emigrated  to  Canada  and  not  one  has  become  a  leper  (Hansen). 

Surgical  treatment  as  required  for  ulcers,  whitlows,  &c. 

Chaulmoogra  oil,  obtained  by  cold  expression  from  the  seeds  of 
gynocardia,  some  species.  It  is  easily  adulterated  and  often  substituted. 
Rub  into  patches,  also  to  be  given  internallv  111  5-10  to  v\  30-40  t.d.s. 
in  capsules  or  in  pill  with  tragacanth  and  soap  or  in  emulsion. 

Limes  remove  the  taste  of  the  oil. 

Rogers  prescribes  gynocardic  acid,  also  known  as  chaulmoogric 
acid,  and  believed  by  some  to  be  the  active  principle  of  the  oil.  This 
latter  contains  almost  certainly  useless  palmitic  acid. 

Dr.  Sandwith  recommends  the  use  of  this  oil  by  hypodermic 
injection. 

Hot  baths  may  be  tried. 

Strychnine  for  nerve  cases  gr.  -r^r>  t.d.s. 

Omit  treatment  every  seventh  week  and  use  ichthyol  ointment  5 
per  cent. 

X  rays  have  been  tried,  Finsen  and  radium. 

Hg.  perchloride  subcutaneously  early  everv  other  dav  is  useful. 

"  Nastin,"  a  neutral  fat  from  Streptothrix  leproides,  combined  with 
benzoyl  chlorine  and  made  into  ampoules  Avith  sterile  olive  oil,  0*0005 
to  o'ooo2  gramme  of  nastin,  once  weekly  can  be  tried. 


PSITTACOSIS  189 

Leproline  (McLeod),  good  results,  but  too  early  to  say  as  to  ulti- 
mate utility. 

Rhizophora  Mangle  used  much  in  Cuba.     (Nicholson  and  Padilla.) 

Lepromata  disappear  definitely  fifth  to  seventh  month  of  treatment, 
they  suppurate  and  scar  or  are  absorbed,  encysted  and  calcified. 

Ulcers  heal  by  eighth  month  and  anesthetic  patches  disappear. 

In  the  ninth  month  the  eyelashes  and  eyebrows  grow  again. 

Patient  is  cured  in  a  year. 

Subcutaneous  injection  of  iodoform.  30  per  cent,  emulsion  in 
olive  oil.     Inject  2-8  c.c.  daily,  first  near  the  lesions. 

Paint  with  the  tincture  externally. 

The  iodine  may  disinfect  the  body,  or  some  bacilli  liaving  been 
killed,  these  set  free  anti-bodies  which  destroy  the  rest. 

Intravenous  injection  of  iodoform.  Place  ^  grain  tablet  of  iodo- 
form powdered,   in  hypodermic  syringe. 

Draw  therein  iii  iii  of  liquid  paraffin  and  111  vii  of  ether.    • 

Seal  needle  with  lanolin  to  prevent  evaporation  of  ether. 

Shake  till  iodoform  dissolves.  Inject  it  aseptically  into  the  medio- 
basilic  or  other  superficial  vein,  given  twice  weekly  at  first,  gradually 
increased  to  gr.  i  five  times  weekly. 

The  nodules  four  to  six  at  a  time  can  also  be  injected  )ii  x  to  111  xxx, 

PSITTACOSIS. 
DEFINITION. 

A  fatal  specific  epizootic  among  parrots,  capable  of  spreading  a 
severe  febrile  condition  to  man. 

AETIOLOGY. 

In  1892,  500  parrots  were  shipped  from  South  America  for  Paris. 
300  parrots  died  en  route  from  enteritis. 
200  parrots  were  sold  in  two  lots  after  arrival  in  Paris. 

In  26  days  an  epidemic  of  psittacosis  broke  out,  affecting  49  persons 
of  which  16  died.  Several  persons  in  the  same  house  were  attacked. 
There  have  been  other  small  outbreaks  since. 

The  organism  is  a  bacillus  of  the  paracoli  group,  closely  related  to, 
but  distinct  from,  the  B.  typhosis  of  Ebert  and  is  pathogenic  for 
parrots  and  other  birds. 

The  feathers  become  infected  w  ith  faecal  matter.  These  are  cleaned 
by  the  bird's  tongue  and  thus  infection  is  spread  among  them. 

Humans  caressing  the  birds  are  infected  by  the  bill  or  through 
some  slight  wound  or  contamination  of  food.  It  rarely  spreads  from 
man  to  man. 


iQO  DISEASES   DUE   TO    BACTERIA 

PATHOLOGY. 

In  parrots  an  enteritis  is  caused,  in  man  a  septicaemia  often  com- 
plicated by  lobular  pneumonia. 

There  is  congestion  and  degeneration  of  the  liver,  kidneys,  lungs 
and  heart. 

SYMPTOMATOLOGY. 

Incubation  7  to  12  days. 

Onset  sudden,  or  insidious,  may  be  much  like  typhoid. 

Temperature  io2°-i04°F.     Pulse  1 10-120,  quick  respirations,  cough. 

Signs  and  symptoms  of  lobular  pneumonia.  Tongue  dry  and 
furred. 

Spleen  enlarged.  Diarrhoea  or  constipation.  Rose  coloured  spots 
on  skin,  patient  dull  and  apathetic. 

If  no  pneumonia,  patient  recovers  in  15  to  20  days. 

If  there  is  pneumonia  the  mortality  is  35-40  per  cent. 

TREATMENT. 

Adapt  treatment  as  for  typhoid  fever  and  pneumonia. 
Quarantine  of  two  weeks  should  be  enforced  for  imported  parrots. 
The  dead  (infected)  burnt  with  their  cages. 

Parrots  should  not  be  fed  by  hand  or  caressed. 

UNDULANT    FEVER.     (MALTA    FEVER.) 
DEFINITION. 

A  chronic  infectious  disease  of  low  mortality  caused  by  the  Micro- 
coccus melitensis  of  Bruce  and  closely  allied  germs,  characterized  by 
a  prolonged  irregular  remittent  fever  and  enlargement  of  the  spleen. 

DISTRIBUTION. 

The  endemic  areas  are  the  coasts  and  islands  of  the  Mediterranean, 
Italy,  France,  Greece,  and  also  India,  especially  the  Punjab.  It  also 
exists  in  S.  Africa,  Uganda  and  the  Sudan,  China,  the  Philippine 
and  Fiji  Islands.  N.  and  S.  America  and  the  West  Indies.  Common 
between  ten  to  thirty  years  of  age  in  both  sexes,  mostly  in  the  warmer 
periods  of  the  year. 

AETIOLOGY. 

The  cause  is  M.  melitensis  (M.  paramelitensis ;  M.  pseudo- 
melitensis.  The  two  latter  differ  from  the  former  in  agglutination  and 
absorption  tests,  causing  para-undulant  fever). 

The  organism  is  a  small,  flagellated  micrococcus,  grows  on  agar 
and  bouillon,  feebly  on  gelatine  without  liquefaction.  Stains  with 
basic  aniline  dves.     Gram  negative.     Mav  often  be  cultivated  from  the 


UN  DU  LA  NT   FEVER  191 

blood,  sometimes  from  the  urine,  occasionally  from  the  faeces.  It  can 
be  found  in  the  spleen,  kidneys,  liver,  lymphatic  and  salivary  glands, 
blood,  bile,  faeces,  urine,  milk,  ?  alimentary  tract.  It  can  live  in  dust 
for  two  months  and  in  water  for  one  month.  It  has  been  found  in 
mosquitoes,  but  they  are  not  proven  infective  agents.  Monkeys  have 
been  infected  and  the  germ  recovered. 

The  organism  has  been  found  by  agglutination  in  50  per  cent,  of 
Maltese  goats  examined  and  has  been  obtained  from  the  milk  of  10  per 
cent. 

Milk  is  the  chief  medium  bv  which  it  is  carried  to  man  even  though 
but  a  little  in  tea  is  taken.  Hence  the  rich  suffer  most  and  hospital 
patients  about  the  Mediterranean  in  particular. 

Captain  Joshua  Nicholson  took  sixty-live  Maltese  goats  on  board  in 
1905.  An  epidemic  of  undulant  fever  followed.  Nearly  all  who  drank 
of  the  milk  suffered. 

Perhaps  goats  become  infected  bv  drinking  human  urine  when 
lacking  salt  :  mules,  asses,  horses,  cows,  rabbits  and  foAvls  can  carry  it 
without  being  obviously  diseased. 

Modes  of  Injection  : — 

(i)  By  the  alimentary  canal  (common). 

(2)  By  the  respiratory  system  (rare). 

(3)  By  the  cutaneous  (very  rare.     Flies  not  proved). 

(4)  By  sexual  intercourse  (possible). 

PATHOLOGY. 

A  general  septicaemia  is  caused  by  the  germ  entering  the  blood- 
stream  by  the  alimentary  mucosae. 

The  spleen  is  enlarged  and  congested. 

Perhaps  an  attack  produces  immunity. 

The  organisms  produce  liaMiioIysins,  the  body  reacting  bv  produc- 
ing agglutinins  lasting  four  to  ten  years,  also  a  specific  serum  which 
can  be  used  for  immunization. 

P.  M. 

Spleen  enlarged,  10  to  44  ounces,  congested,  sometimes  soft  and 
friable. 

Liver  enlarged,  congested,  cloudy  swelling  or  glomerular  nephritis.. 
The  whole  intestine  congested,   colon  sometimes"  ulcerated. 
Lungs  congested  especially  at  the  bases. 

SYMPTOMATOLOGY. 

Incubation  six  to  fourteen  davs. 

Onset  insidious,  headache,  sleeplessness,  anorexia,  general  mus~ 
cular  pains,  perhaps  vomiting  and  constipation  for  about  a  week. 


192 


DISEASES   DUE   TO    BACTERIA 


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194  DISEASES   DUE   TO    BACTERIA 

The  temperature  goes  up  somewhat  ladder-like  to  about  103°  F., 
pulse  80-90. 

Tongue  coated,  edges  red,  sliglitly  congested  fauces. 

Some  bronchial  catarrh,   tender  epigastrium  and  enlarged   spleen. 

This  continues  for  about  two  weeks,  the  temperature  remaining 
between  io3°-io5°  F.  and  then  declines  with  general  improvement.  In 
about  two  davs  a  relapse  occurs.  This  subsides  and  another  follows 
and  these  relapses  and  remissions  may  last  months,  during  which  the 
temperature  is  undulating,  a  marked  rise  in  the  morning  and  a  fall  in 
the  evening. 

The  patient  becomes  more  anaemic  and  wasted.  Dyspepsia  sets  in, 
constipation  or  diarrhoea  reveals  irritation  of  the  intestines.  Throat 
sore,  gums  spongy,  spleen  painful,  lung-  bronchitic,  heart  excitable 
with  h^emic  murmurs,  drenching  sweats,  disagreeable  odour,  crops 
of  sudamina  after  the  bird  week,  big  joints  painful  and  swollen, 
orchitis,  parotitis,  a  general  nervous  disorder  shown  by  insomnia, 
hysterical  emotion,  jDhotophobia,  delirium,  hallucinations  are  trouble- 
some.    A  rapid  ansemia  is  common. 

The  red  cells  show  20-40  per  cent,  loss  with  some  poikilocytosis, 
Hb.  low. 

Decrease  of  polxmorphonuclears,  increase  of  mononuclears  up  to 
80  per  cent. 

Leucocyte  count  normal.  Phagocytosis  and  bactericidal  power  of 
blood  diminished.  Agglutination  test;  diluted  i  in  50  to  i  in  150,  it 
lasts  two  to  seven  years.     Course  of  disease  20  to  300  days,  average  90. 

Convalescence  long  and  slow,  perhaps  six  months. 

Many  soldiers  and  sailors  are  permanently  invalided. 

Mortality  low,  about  2  per  cent. 

Symptoms  arising  in  connection  with  the  genital  organs  are  not 
unknown,  such  as  ovarian  pains,  dysmenorrhoea,  amenorrhoea, 
menorrhagia,  &c.  The  M.  melitensis  has  been  frequently  known  to 
remain  for  long-  periods  in  the  vaginal  mucous  membrane  and  con- 
tagion during  intercourse  is  quite  possible.  Mammitis,  like  orchitis, 
is  a  not  rare  complication. 

The  influence  of  the  fever  upon  a  pregnant  woman  may  vary  very 
much  according  to  the  period  of  gestation,  and  when  the  woman  is 
infected.  Abortion  and  premature  labour  are  favoured  during  the 
fever  when  it  is  high. 

In  some  Mell  authenticated  cases  it  has  been  shown  that  M.  meli- 
tensis can  pass  through  the  placenta  and  infants  born  at  term  generally 
show  signs  of  infection  and  are  weakly. 

Whether  or  not  the  infant  acquires  the  disease  by  drinking  the 
'nfected  milk  of  a  nursing  mother  is  a  debatable  point.     Generally  the 


UNDULANT  FEVER  195 

child  appears  to  have  a  congenital  immunity  as  early  infection  is  rare, 
according  to  the  experience  of  some.  Still  it  would  be  advisable  to 
interdict  the  woman,  whose  mammary  secretion  was  infected,  from 
suckling  her  infant. 

It  is  worth  knowing  too,  that  horses,  mules,  cows,  and  sheep  may 
all  become  naturally  infected,  that  milk  products  may  harbour  the 
germ,  and  that  the  latter  is  fairly  resistant  outside  the  body. 

The  malignant  types  cause  death  from  hyperpyrexia  or  the  typhoid 
state  during-  the  second  or  third  weeks. 

The  intermittent  types  last  from  six  weeks  to  six  months  without 
serious  symptoms. 

The  ambulatory  types  are  dangerous  as  carriers  of  disease. 

COMPLICATIONS. 

Intestinal  ulcers,  haemorrhage,  persistent  vomiting,  diarrhoea, 
hyperpyrexia,  pneumonia,  pleural  effusion,  cardiac  failure,  orchitis, 
parotitis,  arthritis,   neuralgia. 

DIAGNOSTIC  FEATURES. 

The  prolonged  undulant  fever. 

The  profuse  sweatings. 

The  arthritic  symptoms. 

The  agglutination  test. 

Exclude  typhoid  by  a  Widal  reaction  (see  p.  611). 

Exclude  malaria  by  blood  parasites. 

Exclude  kala-azar  by  spleen  puncture. 

TREATMENT. 

Entirely  symptomatic.     General  principles  hold  good. 

The  utmost  nursing  care  is  needed.  Be  careful  to  change  the 
clothes  after  sweating.  The  heart  and  lungs  must  be  carefully 
watched. 

Vaccine  and  yeast  therapy  can  be  tried. 

Give  100-500  millions  of  autogenous  germs  as  a  vaccine. 

Give  yeast,  dr.  ii,  twice  dailv. 

Avoid  goat's  milk  in  endemic  areas  or  sterilize  it  before  using, 

Leave  the  district  as  soon  as  possible. 

PROPHYLAXIS. 

This  is  all  important.  In  Gibraltar  this  fever  disappeared  after  the 
goats  were  removed.  In  Malta  the  case  incidence  amongst  the  British 
troops  was  reduced  from  643  in  1905,  to  7  in  1907  and  i  in  1910. 

(i)  General  measures.  Notification,  isolation,  disinfection,  steril- 
ization of  water  and  milk,  good  hygiene. 


196  DISEASES   DUE   TO   BACTERIA 

(2)  Personal    measures.       Cleanliness,    vaccine,    care    in    nursing 
mothers. 

(3)  Veterinary  measures.     Examinations  of  blood  and  milk  of  all 
goats  and  other  suspected  animals. 

Slaughter  of  infected  animals. 

Prophylactic  vaccines  to  all  goats. 

Prevention  of  the  importation  of  infected  animals. 

BACILLARY  DYSENTERY. 
DEFINITION. 

Acute  or  chronic,  sporadic,  endemic  or  epidemic,  specific  infective 
intestinal  disorders  caused  by  several  varieties  of  bacteria,  associated 
with  tenesmus,  abdominal  pain,  frequent  mucous  and  blood  stools. 

DISTRIBUTION. 

Universal,  but  especially  in  warm  climates  and  where  sanitation  is 
defective  as  in  jails  and  asylums,  during  famines  and  war-time. 

In  temperate  climates  the  dysentery  bacillus  causes  the  infantile 
diarrhoeas.  There  seems  more  prevalence  at  the  end  of  a  dry  season, 
perhaps  because  of  the  infection  of  water  by  flies. 

AETIOLOGY. 

There  are  numerous  types  of  true  dysentery  bacilli  and  of  pseudo- 
dysenteric  bacilli.     There  are  three  main  types  :  — 

(i)  Bacillus  dysenteriie  of  Shiga-Kruse,  which  does  not  ferment 
mannite. 

(2)  Bacillus  dysenterise  of  Flexner,  which  ferments  mannite,  form- 
ing an  acid  in  it.  These  bacilli  are  found  in  the  dejecta,  and  can 
be  scraped  from  the  bowel  post  mortem.  Agglutination  A\ill  help  in 
their  differentiation. 

(3)  The  Bacillus  of  Hiss.  They  belong  to  the  Coli  group,  and 
the  members  thereof  have  the  following  characteristics  :  — 

They  are  Gram-negative,  non-sporing,  non-resistant,  none  liquefy 
gelatine,  all  attack  glucose,  all  change  the  reaction  of  milk,  all  form 
creamy  growths  on  agar. 

For  specific  characteristics,  see  p.  619. 

The  infection  is  b}'  faeces,  flies,  dust,  soiled  clothes,  contaminated 
water  or  soil.  Convalescents  act  as  carriers.  11  per  cent,  of  persons 
in  an  epidemic  were  found  to  be  carriers. 

The  bacilli  may  live  in  the  bowel,  producing  no  symptoms  until 
the  patient's  resistance  is  lowered,  when  the  typical  disease  mav  show 
itself.  After  the  first  few  days  other  bacteria  may  overcrowd  the 
dysentery  bacillus  so  as  to  make  its  isolation  difficult. 


BACILLARY   DYSENTERY  197 

PATHOLOGY. 

The  bacilli  are  ingested  with  food  or  water  and  proceed  to  the 
intestine,  where  they  grow  and  muUiply.  There  they  form  toxins, 
one  acting  upon  the  lower  bowel  and  the  other  on  the  nervous  system. 
These  are  absorbed  by  the  blood.  The  first  is  excreted  into  the  lower 
bowel  and  causes  :  — 

(i)  In  acute  cases. 

An  exudation  of  lymph  into  the  submucosa  and  mucosa. 

This  coagulates  and  is  invaded  by  cells. 

The  capillaries  are  pressed  upon  and  the  blood  supply  cut  off  for 
small  areas. 

Coagulative  necrosis  and  thrombosis  of  vessels  ensues ;  the  mucosa 
and  the  muscularis  mucosae  are  destroyed. 

This  forms  a  fibrous  or  diphtheroid  membrane  on  the  ridges  first. 

This  membrane  contains  micro-organisms  and   leucocytes. 

The  membrane  separates  oft"  in  flakes,  leaving  ulcers. 

These,  at  first  superficial,  become  deeper  and  larger. 

The  peritoneum  becomes  oedematous  and  mixed  infection  is 
common. 

The  condition  can  be  summed  up  thus  :  — 

(i)  Intense  hyper^emia,  the  mucosa  is  swollen,  corrugated  and 
h^emorrhagic. 

(2)  Necrosis  and  fibrinous  exudation  with  pseudo-membrane 
formation. 

(3)  Ulceration,  at  summit  of  folds,  extending  deeply  and  laterally. 
The  ulcers  heal   by   scar  formation,   and  become   pigmented  as  a 

result  of  the  HoS  of  the  bowel  acting  upon  the  iron  of  the  blood. 
The  other  toxin  causes  peripheral   neuritis. 
Septicaemia  is  very  seldom  caused, 
(2)  In  chronic  cases. 

The  mucosa  and  the  whole  gut  is  thickened  and  granular. 

The  ulcers  have  thickened  edges. 

Scarring  causes  strictures  of  the  bowel  with  dilatation  above. 

A  typical  ulcer  :  — 

(i)  Site,  on  the  ridges  of  the  large  intestines. 

(2)  Edges,   irregular  and  thickened. 

(3)  Base,  may  be  formed  of  any  of  the  coats. 

(4)  Result,  tendency  to  contract  on  healing.  , 
These  descriptions  will  also  indicate  the  post-mortem  findings. 
There  would  be  adhesions  and  signs  of  peritonitis,  and  parts  of  thf 

gut  may  present  a  black  friable  mass. 


198  DISEASES   DUE   TO    BACTERIA 

SYMPTOMATOLOGY. 

There  is  an  endless  variety  in  character,  urgency  and  significance. 

The  nearer  the  lesion  to  the  rectum  the  more  urgent  is  the  tenesmus. 

The  nearer  the  caecum  the  more  griping.  There  is  never  liver 
abscess. 

We  will  group  them  thus  :  — 

Acute,  Chronic,  and  Infantile. 

(i)  Acute  bacterial  dysentery . 

Incubation  twenty-four  hours  to  six  days. 

Onset. — Sudden,  abdominal  pain  about  the  umbilical  region  first. 

Incessant  call  to  stool,  griping,  tenesmus,  very  small  stools  of  slimy 
mucus,  and  later  blood-stained.  50-200  in  twenty-four  hours.  Passage 
of  a  stool  gives  no  relief. 

Slight  or  moderate  fever,  99°-io3°  F.  Great  thirst,  foul  tongue, 
dry  skin.  Anus  becomes  painful,  prolapse  not  uncommon.  Blood  in 
stools,   rapid  exhaustion,   sleeplessness,    restlessness. 

Vomiting  is  not  common.  There  may  be  constipation  of  the  upper 
bowel  with  diarrhoea  of  the  lower,  recognized  bv  distension. 

The  typical  dysenteric  motions  have  no  faecal  odour. 

The  pulse  is  quickened,  especially  if  much  blood  is  passed  per 
rectum,  and  may  become  irregular. 

Bad  signs  are  :  — 

Irregular  and  rapid  pulse,  subnormal  temperature,  hiccough, 
diminished  number  of  stools  in  midst  of  attack  during  the  second  or 
third  week. 

Good  signs  are  :  — 

Motions  more  faeculent,  less  numerous,  disappearance  of  blood  and 
mucus,  less  pain  and  tenesmus. 

Cases  have  been  known  to  improve  much,  and  then  with  a  slight 
faeculent  diarrhoea  the  patient  has  died  wiiliin  a  few  hours  from 
gangrenous  dysentery,  or  with  the  latter  type  there  mav  be  thin, 
watery,  dirty,  foul  stools,  with  sloughs  of  every  shape  and  colour. 

Profuse  hc-emorrhage  is  always  possible. 

Others  may  commence  with  rigors,  and  the  temperature  may  keep 
high,  1030-105°  F.,  with  mental  symptoms  as  stupidity,  sleeplessness, 
delirium,  abscesses,  carbuncles  and  bed-sores,  simulating  somewhat 
enteric  fever.  Death  may  ensue  in  a  few  days  from  exhaustion, 
toxaemia  or  hyperpyrexia. 

The  stools. 

In  an  average  case  they  consist  of  odourless  gelatinous  blood  and 
extremely  tenacious  mucus  Avhich  adheres  to  the  pan. 

In  three  to  four  days  they  become  of  a  more  purulent  nature,  vellow 
in  colour,  and  contain  less  blood.     Later  bile  is  seen,  which  indicates 


BACILLARY   DYSENTERY  199 

that  the  contraction  of  the  lower  part  of  the  large  gut  has  passed  off. 
Faecal  matter  may  then  be  passed.  A  stool  of  glairy  mucus,  like 
sputum,  is  usually  a  catarrhal  inflammation  due  to  the  Y  bacillus. 

In  the  most  acute  fulminating  varieties  the  stools  contain  much 
blood,  and  have  been  compared  to  "meat  washings." 

When  necrosis  of  the  mucous  membrane  has  taken  place  the  stools 
may  be  choleraic,  but  may  contain  dark  green  sloughs  of  mucosa 
(Bahr). 

(2)  Chronic  bacterial  dysentery. 

Insidious  onset  or  may  ensue  after  an  acute  attack.  The  bowel  is 
not  healthy,  and  any  dietetic  error,  chill,  fatigue,  or  indulgence  will 
cause  the  symptoms  to  appear. 

The  stools  are  loose,  five  to  ten  per  diem,  partly  faecal,  much  mucus, 
rarely  blood,  like  "  frog's  spawn  "  or  "boiled  sago."  The  tongue  is 
glazed  red,  anaemia  and  emaciation  are  progressive,  cachexia  is 
apparent. 

The  digestion  is  impaired,  all  functions  are  beloAv  par  resulting 
from  anemia  and  toxaemia.  Fermentation  produces  much  intestinal 
gas. 

These  symptoms  may  subside  and  recur  at  intervals. 

The  disease  may  continue  until  death  from  exhaustion  or  some 
intercurrent  disease,  or  it  may  clear  up  spontaneously. 

If  no  blood  is  passed  it  is  commonly  dysenteric  diarrhoea. 

(3)  Dysenteric  infantile  diarrhoea. 

This  is  an  extremely  common  disease  in  the  tropics. 

Flexner's  bacillus  commonly,  and  Shiga's  bacillus  rarely,  are 
believed  to  be  the  exciting  agents. 

The  symptoms  resemble  those  of  the  enteric  type  of  chronic 
dysentery.     It  begins  by  vomiting  and  a  temperature  of  io3°-io5°  F. 

The  abdomen  is  distended  and  tender. 

The  stools  are  facal,  but  often  green  w-ith  blood  and  mucus. 

The  fever  is  remittent.     There  may  be  repeated  attacks. 

Death  may  be  from  exhaustion  or  convulsions. 

Recovery  may  take  place,  but  the  convalescence  is  always  slow. 

COMPLICATIONS. 

Peritonitis  with  or  without  perforation  (rare). 
Pleurisy,   pericarditis,  endocarditis. 

Arthritis,  tenosinovitis,   j^erhaps  the  result  of  secondary   infection. 
Ana?mia  and  dropsy. 

Peripheral  neuritis,  frequent  in  mild  forms;  one  nerve  only  may  be 
involved. 

Iritis,  toxaemia,  yields  to  atropine. 


200  DISEASES   DUE   TO    BACTERIA 

Parotitis,  abscesses,  rarely  pyaemia. 

Hemorrhage  in  gangrenous  cases. 

Appendicitis  may  set  in. 

T^'phoid  is  a  most  serious  complication  and  has  occurred. 

SEQUELiE. 

Stenosis  of  the  large  bowel  due  to  cicatricial  contraction  of  the 
healing  ulcers. 

Constipation  and  diarrhoea  intermitting  result  of  above  condition. 
Colic  and  vomiting,   meteorism. 

DIAGNOSIS. 

Inflamed  haemorrhoids  can  be  seen  and  felt. 

Syphilis  of  the  rectum  can  be  diagnosed  by  the  Wassermann 
reaction  and  excluded  by  "606"  injections. 

Rectal  carcinoma  can  be  excluded  by  the  history,  examination  with 
finger  and  microscope. 

Intussusception  is  very  sudden  in  onset,  the  abdomen  is  not  tense, 
a  sausage-shaped  tumour  is  felt.    Operation  will  discover  and  correct  it. 

Malarial  dysentery  parasites  will  be  seen  in  the  spleen  by  puncture 
and  smear. 

Kala-azar  dysentery  parasites  will  be  seen  in  the  spleen  jjuncture 
and  smear. 

Amoebic  and  balantidic  dysentery  by  microscopic  examination  of 
fasces. 

A  bacteriological  examination  of  the  fasces  should  be  carried  out. 

The  agglutination  reaction  should  be  tried  with  the  cultures  pre- 
pared from  the  fasces  and  other  known  organisms. 

PROGNOSIS. 

Mild  acute  attacks;  good  recovery  the  rule. 
Severe  acute  attacks;  poor,  mortality  high. 
Gangrenous  acute  attacks;  bad,   nearly  all  die. 
12-25  ppi'  cent,  in  all  classes  together  die. 
The  lower  down  the  bowel  the  better  the  prognosis. 
The  higher  up  the  bowel  the  worse  the  prognosis. 
Early  prophylactic  serum  improves  the  prognosis. 
New  arrivals  in  the  tropics  suffer  more  than  native  residents. 
In  Japan,  the  mortality  was  reduced  from  35  per  cent,  to  9  per  cent, 
by  serotherapy. 

TREATMENT. 

(i)  Acute  attacks. 
Rest  in  bed.     Bland  diet. 

Use  of  urine  bottle  and  bed  pan.  Constipation  must  be  overcome, 
no    matter   how    long   the    patient    has    been    passing    mucus.     Damp 


BACILLARY   DYSENTERY  201 

cotton-woo!  instead  of  sanitary  paper  should  be  used.  Stools  to  be 
saved  for  physician's  inspection.     Protection  of  stools  from  flies. 

Disinfection  of  stools  with  carbolic  acid. 

Give  castor  oil  5ss  with  opium  tincture,  10  minims;  much  opium 
causes  constipation  and  distension  of  gut  and  flatus. 

In  a  few  hours  give  astringents  :  — 

^     Bismuth  salicylate         gi-  v 

Salol         gr.  V 

In  cachets  two-hourly  at  first. 

High  rectal  enema,  boric  acid  i  in  500;  normal  saline  gr.  v  to  51 
are  well  borne  in  mild  cases. 

In  severer  cases  give  a  polyvalent  or  other  serum  (Shiga)  as  soon 
as  possible. 

(i)  In  mild  cases  10  c.c.  only. 

(2)  In  medium  cases  10  c.c.  twice,  six  hours  between. 

(3)  In  severe  cases  10  c.c.  twice  daily  for  three  days,  or  40-80  c.c. 
intravenously  first  day,  60  c.c.  second  day,  60  c.c.  third  day. 

This  hastens  the  cure,  ameliorates  the  symptoms,  and  reduces  the 
mortality. 

In  connection  with  the  rapid  preparation  of  serum.  Professor 
Flexner  has  hastened  the  process  considerably.  In  summarizing  his 
work,  he  says  :  — 

Antidvsenteric  serum  can  be  safely  prepared  in  the  horse  by  the 
method  of  three  successive  intravenous  injections  of  living  cultures 
with  intervening  rest  periods  of  seven  days. 

When  this  method  of  immunization  is  employed,  the  specific  anti- 
bodies responsible  for  agglutination  and  protection  appear  early  and 
rise  rapidly. 

By  inoculating  alternately  living  dysentery  bacilli  belonging  to 
the  Shiq-a  and  Flexner  groups  a  polyvalent  serum  of  high  titre  may 
be  prepared. 

A  polyvalent  serum  so  produced  should  be  suitable  for  the  thera- 
peutic treatment  of  acute  bacillary  dysentery,  irrespective  of  the 
particular  strain  or  strains  of  the  dysentery  bacillus  causing  the 
infection. 

An  effective  antidvsenteric  serum  suitable  for  therapeutic  employ- 
ment in  man  can  be  prepared  in  the  horse  in  about  ten  weeks. 

Calcium  chloride  or  lactate  gr.  15  to  gr.  30  is  good. 

Salines  are  useful,  especiallv  when  sera  are  not  available  or  are 
not  very  successful.  Stop  on  the  third  da^-  if  no  impriivement,  other- 
wise continue  :  — 

5;     Mag.  sulph oil 

Sod.  sulph.  ...  ...  ...         5ii 

Aqua.  ad.  ...         ...         ...         ,5! 

5i  two  hourly  until  two  days  after  motions  are  feculent. 


202  DISEASES   DUE   TO    BACTERIA 

Laudanum  fomentations  to  abdomen  for  pain. 

Suppositories  of  morphia  or  cocaine  for  tenesmus. 

Or  hypodermic  injection  of  morphia  gr.  i. 

Reduce  prolapse  and  apply  hazeline  or  gall  and  opium  ointment. 

Rectal  tubes  will  permit  gas  to  escape  and  allow  of  lavage,  but  pain 
often  contra-indicates  this. 

After  acute  stage  bismuth  subnitrate  gr.  10-20,  two-hourly. 

Rectal  enemata  of  boric  or  tannic  acid. 

Milk  and  fruit  good. 

Calomel,  ^  gr.,  hourly,  has  been  tried. 

Yellow  santonin  in  olive  oil  and  sour  milk  have  their  advocates. 

Appendioostomy  will  permit  the  washing  out  of  the  bowel  from 
above  in  gangrenous  cases. 

(2)  Chronic  attacks. 

Treatment  as  for  mild  cases  sometimes  suffices. 
Diet. — The  bowel  must  have  rest. 

Albumin   water  and  whey  only  at  first.      Then   diluted   milk  and 
barley  water  with  sodium  bicarbonate. 
Thin  arrowroot,  malted  milk. 
Chicken  broth  and  milk  puddings  later. 
Lightly  boiled  eggs  and  chicken. 
In  severe  cases  give  small  quantities  two-hourly. 
Food  must  be  well  masticated  later. 
Avoid  much  brandy,  strong  meat  essences,  and  fruit. 
High  bowel  irrigation  of  silver  nitrate  with  buttocks  raised. 
Solution,   l^-i   gr.  to  the  ounce.     This  gives  the  best  results  of  all 
astringents.     Precede  with  two  pints  of  i  per  cent,  sodium  bicarbonate 
to  remove  mucus.     Sera  should  be  tried. 

Tannigen,  gr.  v,  three  to  six  times  daily,  or 

Tannalbin,  gr.  xv,  three  to  six  times  daily  have  given  good  results. 
Liquid  paraffin  is  always  good,   soothing-  the  bowel,   breaking  up 
the  scybalous  masses,  and  is  mildly  antiseptic. 
Pilula  plumbi  cum  opii,  gr.  iv,  four-hourlv. 
Autogenous  vaccines  can  be  tried. 
Appendicostomy  is  preferred  bv  some. 
(3)  lufaniilc  diarrhoea. 

Castor  oil  5i-5ii,  followed  by  calomel  gr.  1,  or  grey  powder  gr.  ^ 
each  hour  until  six  doses  have  been  given  in  a  child  of  two  vears. 
Later  tannigen  gr.  iii  oi-  tannabin  gr.  v,  ihree-hourh'. 
Sera  are  good  when  bacilli  are  diagnosed,  5-10  c.c.  twice  daily. 
Treat  convulsions  by  bromides,   gr.  xv  in  enemata.     General  prin- 
ciples hold  good. 


4» 


CHOLERA 


203 


CHOLERA. 
DEFINITION. 

An  acute,  specific,  endemic  or  epidemic  disease,  caused  by  Koch's 
V^ibrio  cholerai,  1883,  and  characterized  by  violent  purging,  rice-water 
stools,  vomiting,  muscular  cramps,  suppression  of  urine,  collapse  and 
high  mortality. 

DISTRIBUTION. 

The  name  is  of  Greek  origin,  and  was  perhaps  applied  because  the 
violent  watery  stools  resembled  water  rushing  from  a  spout. 

It  has  been  known  in  India  since  the  most  ancient  times. 

Ahmed  Shah's  army  was  decimated  by  it  in  1438.  There  were 
several  outbreaks  after  this  in  India,  Burmah  and  Ceylon.  The  first 
great  epidemic  outside  India  was  from  181 7  to  1827,  when  China  was 
infected. 

Although  cholera  is  not  an  endemic  disease  in  Europe,  its  mani- 
festations in  the  19th  and  20th  centuries  killed  millions  of  its  people. 
There  have  been  nine  invasions  of  Europe  in  a  little  over  80  years. 
The  chief  centre  of  attack  was  about  the  Caspian  Sea  in  Russia.  All 
the  invasions  probably  came  from  India  by  indirect  routes.  The 
endemic  centres  of  Java,  Indo-China  and  the  Philippines  were  probably 
not  implicated.  An  excellent  summary  of  these  attacks  is  given  by 
Professor  W.  J.  Simpson  as  follows  :  — 


Epidemics 

in 

Europe 

Interval 

Principal  entrance   ;    '^J^IH 
gate  into  Europe            ^^^^ 

invasion 

Number  of 

years 

continued  in 

Europe 

General  characters 

1823 
1830-37 

1847-52 

Astrakhan 

'! 

7 
10 

Less  than 
a  year 

7 
6 

Did    not   travel  farther  west 
than  Astrakhan.     The  Persian 
and  Turkish  armies,  which  were 
at  war  with  one  another,  sufifered 
severely. 

Severe  and  widespread.  Very 
virulent  among  the  Russian  and 
Polish    troops.      The    war   was 
believed  to  be  the  great  cause 
of    the    rapid    propagation     of 
cholera     in      Europe.       Great 
epidemic    among    the    pilgrims 
at  Mecca. 

Severe  and  widespread.     In- 
vaded   a    larger    area    of    the 
world's    surface    than    that    of 
1830-37      and      more      deadly. 
Epidemic  at  Mecca. 

204 


DISEASES   DUE   TO    BACTERIA 


Epidemics 
in 

Principal  entrance 

Interval 
in  years 
between 

Number  of 

years 

continued  in 

Europe 

Genera!  characters 

Europe 

gate  into  Europe 

each 

invasion 

1852-59 

Astrakhan 

nil 

8 

More  severe  and  widespread 
than  previous  epidemics.  On 
its  way  through  Persia  it 
attacked  violently  troops  of  the 
Shah.  Cholera  aft'ected  the 
troops  in  the  Crimean  War. 
In  1859  it  attacked  the  French 
troops  in  Algeria,  and  the 
Spanish  troops  in  Morocco. 

1865-74 

Constantinople 

6 

JO 

Severe,  but  more  Imiited  in 
diffusive  power. 

1884-87 

Marseilles 

and 

Toulon 

10 

4 

Less  severe  and  limited. 
Spain  lost  180,000  people,  and 
Italy  50,000. 

1892-96 

Baku 

5 

5 

Less  severe  and  limited. 
Hamburg  lost  9,000  people  out 
of  17,000  attacked.  It  owed  its 
origin  to  the  great  bathing 
festival  at  Karagola,  on  the 
Ganges.  This  only  occurs  once 
in  thirty  years,  and  the  officials 
were  not  prepared  for  it. 
CIh  lera  broke  out  among  the 
pilgrims,  and  spread  rapidly. 

1905-12 

Baku 

and 

Astrakhan 

9 

8 

Comparatively  mild  and 
limited.  It  killed  100,000  in 
Russia  during  1910. 

1912 

Constantinople 

Mild  and  liinited.  Prevailed 
among  the  Turkish,  Bulgarian, 
Greek,  and  Serbian  troops. 

The  relation  of  cholera  epidemics  to  wars  is  all-important. 

It  is  of  interest  to  know  that  during  the  Napoleonic  wars  the  disease 
was  not  known  to  Europe,  so  that  these  were  free  from  this  devastating 
malady. 

(i)  In  the  Egyptian  War  of  1882-3  the  civil  population  lost  50,000 
from  cholera,  but  the  troops  were  little  afYected  by  it. 

(2)  Cholera  was  virulent  during  the  Russo-Polish  War  of  1831. 

(3)  After  the  Crimean  War  came  the  infection  of  all  Europe. 

(4)  After  the  Balkan  War  its  distribution  was  widespread.  Both 
the  French  and  British  armies  and  fleets  sufTered.  There  were  prob- 
ably about  18,000  cases  behind  the  Chataldja  lines,  whence  it  was 
conveyed  to  the  Bulgarian  army,  and  later  to  the  Greek  and  Serbian 
armies. 

(5)  The  Great  European  War  of   1914  :  — 

At  the  commencement  of  the  War  cholera  prevailed  in — 
Russia,  the  Province  of  Podalia. 
Hungary,  53  different  centres. 


CHOLERA  205 

Austria,  39  different  centres. 

Germany,  10  different  centres. 

Turkey,  2  different  centres. 

Persia  and  Arabia  are  seldom  free  from  the  scourge. 

In  1915  the  Russians  tool^  cholera  to  their  Austrian  guards  and  to 
the  civil  population.  There  were  then  30,000  cases  with  16,000  deaths 
in  Austria,  and  5,000  cases  with  3,000  deaths  in  Hungary. 

During  the  same  year  there  were  147,000  deaths  in  India,  of  which 
68,000  were  in  Bengal. 

Tropical  and  South  Africa,  the  Azores,  the  Pacific  Islands  have 
not  yet  been  infected.     The  principal  endemic  centre  is  lower  Bengal. 

It  always  adopts  channels  of  human  inter-communication  ;  ships, 
rivers,  roads,  railways,  producing  a  widespread  epidemic  in  places  of 
bad  sanitation. 

iETIOLOGY. 

The  existing  cause  is  Koch's  comma  bacillus. 


),hi 


Cholera  spirilla.     (From  Pitfield's  "  Bacteriology.") 

Predisposing  causes  are  low-lying  areas,  contaminated  soils,  unripe 
fruit,  lowered  vitality  from  any  cause,  as  seen  in  gaols. 

Infection  is  by — 

(i)  Direct  contact.  A  medical  man  examined  a  patient  suffering 
from  cholera,  then  had  his  lunch.  Patient  and  doctor  were  both  dead 
in  twenty-four  hours.     Care  is  required  in  performing  autopsies. 

(2)  Fomites  form  a  common  means  of  infection. 

(3)  Water  is  the  medium. 

The  comma  bacillus  passes  out  with  the  faeces,  and  as  it  lives  and 
multiplies  in  water  for  163  days  or  more,  a  place  having  a  poor  sanitary 
system  would  have  all  the  conditions  favourable  for  an  epidemic. 

Hampstead,  a  cholera-free  place  in  1854,  was  infected  by  a  lady  and 


2o6  DISEASES   DUE   TO    BACTERIA 

her  servant  ^^■ho  drank  water  taken  to  them  from  the  I3roa(l  Street  well, 
for  Avhich  they  had  a  special  Hking. 

The  Hamburg  and  Akona  instance  is  well  known.  Both  towns 
used  water  from  the  river  Elbe  for  drinking  purposes.  The  former 
townspeople  did  not  filter  their  water;  an  epidemic  of  cholera  broke 
out,  and  there  were  8,000  deaths,  or  i3"4  per  cent,  of  the  population. 

The  latter  people  filtered  their  water,  and  during  the  epidemic  they 
only  had  328  deaths,  2*1  per  cent,  of  the  population. 

(4)  Milk  is  especially  dangerous,  as  it  affords  a  good  growing 
medium. 

(5)  Carriers  are  extremely  dangerous;  though  not  obviously  ill 
themselves,  they  carry  and  give  out  virulent  comma  bacilli  in  their 
faecal  excretions. 

(6)  The  bacillus  vibrio  has  been  found  upon  and  within  the  bodies 
of  flies,  hence  these  should  be  considered  an  important  means  of  trans- 
mission.    Ants,  too,  should  be  looked  upon  with  suspicion. 

(7)  Green  vegetables  eaten  raw,  such  as  lettuces,  watercress  and 
tomatoes  are  liable  to  become  infected.  In  the  East  vegetable  gardens 
are  often  contaminated  with  human  faecal  matter. 

For  details  of  the  organism,  see  p.  621. 

PATHOLOGY. 

The  vibrio  has  a  local  habitat,  living  and  growing  in  the  small 
intestinal  mucosa,  epithelial  cells,  glands  and  lumen  giving  off  in  all 
probability  an  endocellular  toxin  w^hich,  when  set  free  and  absorbed, 
causes  the  general  symptoms.  This  toxin  causes  the  blood  elements 
to  enter  the  blood  thus  :  First  water,  then  inorganic  salts,  especiallv 
sodium  chloride,  later  phosphates  and  potassium  salts,  and  still  later 
organic  substances.  This  produces  a  great  concentration  of  blood 
(T073-1078)  and  an  increase  of  hb.  and  red  cells  to  8,000,000  per  c.mm., 
also  of  white  cells  up  to  60,000  c.mm. 

The  alkalinity  of  the  blood  is  decreased  and  the  coagulative  power 
altered. 

This  concentration  of  the  blood  causes  a  fall  in  the  blood  pressure, 
shown  by  the  feeble  compressible  pulse  (50-80  mm.  of  Hg). 

The  result  of  this  low  blood  pressure  is  that  the  urine  is  scanty, 
high  sp.  gr.,  albumin,  casts  and  much  indican. 

Perhaps  the  blood  pours  out  bactericidal  substances. 

POST  MORTEM. 

Rigor  mortis  marked  and  early.  Rise  of  temperature  and  muscular 
movements  after  death  not  uncommon.  Tissues  dry.  Blood  thick^ 
may  be  tarry. 

Stomach  empty,  vessels  injected. 


CHOLERA  207 

Small  intestine  contains  greyish  grumous  material,  consisting  of 
food  particles,  epithelial  cells,  red  and  white  corpuscles,  and  micro- 
organisms.    Mucosa  hyper^emic  and  swollen,   sometimes  ecchymosis. 

Salivary  and  mesenteric  glands  enlarged. 

Liver  congested,  loaded  with  blood,  ducts  full  of  bile. 

Spleen  shrivelled  and  small. 

Kidneys  enlarged,  tubules  blocked  with  granular  debris,  cloudy 
swelling. 

R.  heart  dilated.  \"enous  system  congested  with  dark,  thick,  tarry 
blood. 

L.  heart  empty.     Arterial  system  empty. 

Lungs  dry,  anaemic  and  collapsed. 

Urinary  bladder  empty  and   contracted. 

The  vibrios  are  usually  confined  to  the  intestines,  but  they  have 
been  found  in  the  liver,  kidney  and  heart. 

SYMPTOMATOLOGY. 

Incubation  three  hours  to  six  days. 

Typical  form. 

Onset  sudden  as  a  rule;  sometimes  malaise  precedes  it. 

There  are  three  stages. 

(i)  Evacuation  stage. 

Diarrhoea  with  or  without  colicky  pains.  Loose  f^eculent  motions, 
followed  quickly  by  the  typical  rice-water  stools  containing  numerous 
white  flakes  of  mucus,  epithelial  cells  and  vibrios. 

Vomiting  early,  food  first,  then  watery  fluid  with  bile  and  some- 
times blood,  then  rice-water  material. 

(2)  Algide  stage. 

Always  much  thirst,  sometimes  hiccough,  urine  diminishes  and 
may  cease. 

Subcutaneous  tissues  give  up  their  fluid  and  the  facies  alter,  e.g., 
nose  sharp,  cheek-bones  prominent,  eves  sunken,  skin  of  fingers 
wrinkled. 

B.P.  falls,  pulse  weak  and  rapid,  cyanosis,  dyspncea,  huskv  voice. 

Painful  muscular  cramps,  in  calf,  arm  and  abdomen  especially. 

Reflexes  diminish.     Mind  clear,  patient  apathetic  between  cramps. 

Skin  cold,  axillary  temperature  lowered,  rectal  raised. 

Pulse  runs,  heart  weak  and  irregular,  urine  suppressed,  tempera- 
ture subnormal. 

Comatose  and  death  in  twelve  to  thirty-six  hours. 

(3)  Reaction  stage. 

Improvement  may  commence  at  any  stage.  The  symptoms 
gradually  disappear  and  indications  of  normal   health  return. 


2o8  DISEASES   DUE   TO    BACTERIA 

Convalescence  may  be  rapid,  or  a  secondary  febrile  condition  sets 
in  and  lasts  two  days  to  tAvo  weeks. 

The  status  typhosus  is  not  uncommon,  especially  just  before  death. 

Raised  temperature,  dry  brown  tongue,  low  muttering  delirium, 
tremblings,  toxic  rashes,  erythematous,  papular  or  ha^mcrrhagic  in 
nature. 

Other  forms  may  show  predominance  of  purgation  symptoms. 

Other  forms  may  show  predominance  of  cramps. 

Others  may  show  signs  of  collapse  and  die  before  diarrhoea  and 
vomiting  sets  in. 

Other  forms  ma}^  show  nothing  but  vibrios  in  fasces. 

Cases  are  usually  worst  at  the  commencement  of  an  epidemic. 

The  case  mortality  averages  about  50  per  cent. 

A  coagulum  in  the  R.  heart  or  spasm  of  the  pulmonary  vessel 
refusing  to  transmit  the  thickened  blood  may  cause  sudden  death. 

COMPLICATIONS. 

Hyperpyrexia  is  rare.  Abortion  the  result  of  contraction  (cramp) 
of  uterus  possible. 

Secondary  infections  account  for  most  complications  as  pneumonia, 
enteritis,  nephritis,  parotitis,  corneal  ulceration.  There  may  be  errors 
of  refraction. 

DIAGNOSIS. 

Easy  in  epidemic,  difficult  in  sporadic  cases. 

An  extremely  careful  bacteriological  examination  is  necessary  to 
detect  the  true  \^ibrio  choleras  of  Koch.  In  dispatching  material  for 
diagnosis,  collect  and  sample  a  piece  of  bowel  ligatured  into  a  boiled 
glass  bottle  well  stoppered.     No  antiseptic  to  be  used. 

Methods  of  diagnosis:  — 

(i)  Make  ordinary  films  of  the  white  flakes.  Stain  with  diluted 
carbol  fuchsin  (i  in  50)  10  minutes,  or  with  Lofifler's  blue  5 
minutes. 

If  a  fish-in-stream  arrangement  of  curved  rods  be  seen  cholera 
can  be  strongh^  suspected. 

(2)  Smear  the  surface  of  a  lactose-agar  plate  (MacConke^-'s  media) 
w4th  a  rice-like  flake,  using  a  bent  sterile  glass  rod.  Inoculate 
whh  ihe  same  rod  not  recharged  two  more  plates  and  inoculate 
at  35°C. 

If  small,  delicate,  yellowish,  roundish  dots  appear  within  twelve 
to  eighteen  hours,  cholera  vibrio  can  be  suspected. 
Examine  the  germs  of  a  colony,  if  very  active,  comma-like  or 
straight,  if  it  agglutinates  with  anticholera  serum  in  a  dilution 
down  to  I  in  4,000,  it  is  in  all  probability  cholera  vibrio. 


CHOLERA  J09 

(3)  Mix  directly  a  drop  of  the  stools  with  immune  serum. 
If  agglutination  suspect  cholera  vibrios  (Dunbar). 
This  is  useful  only  when  the  vibrios  are  very  numerous. 

(4)  Inoculate  four  tubes  of  peptone  water  with  sample  of  stool 
\  CO.,  h  c.c,  I  c.c,  2  c.c,  respectively. 

A  scum  on  the  surface  of  the  medium  in  8-10  hours  is  suspicious 
of  cholera.  Examine  scum  for  comma  vibrio,  inoculate  plates 
with  the  germs  to  confirm.  Add  to  peptone  water  medium  a 
few  drops  of  pure  H2SO4.  In  true  cholera  the  indol  reaction 
is  present  in  8-10  hours. 

(5)  Inoculate  the  surface  of  three  serum  tubes  with  the  sample  and 
incubate  at  35°C.  If  no  liquefaction  in  16  hours,  it  excludes 
cholera. 

If  liquefaction  in  16  hours,  exclude  cholera  by  plating  out,  &c. 
If  liquefaction  then,  the  vibrio  may  be  present,  plate  out  and 
further  examine. 

(6)  Inoculate  a  sedimentative  tube  of  peptone  water  and  immune 
serum  with  the  faecal  sample.  Incubate  at  37°  C.  for  three  to 
seven  hours. 

If  true  cholera,  numerous  small  flocculi  of  agglutinating 
vibrios,  at  first  suspended,  sink  to  the  bottom  (Bandi). 

(7)  Inoculate  with  fa?cal  sample  media  of  pure  bile  mixed  with  3 
per  cent,  of  a  10  per  cent,  solution  of  XaoCOj. 

Incubate  at  37°C.     Plate  and  further  examine. 
In     epidemics     due     to     cholera     nostras,     mushroom     poisoning, 
bacterial    food    poisoning,    trichinosis,    pernicious    malarial    fever,    all 
have  a  low  mortality  as  compared  with  cholera.     If  an  epidemic  has 
over  50  per  cent,  mortality  it  is  cholera. 

TREATMENT. 

The  indications  are  :  — 

To  destroy  and  remove  the  vibrios. 

To  neutralize  the  toxins. 

To  prevent  secondary   infections. 

To  relieve  the  symptoms. 
B^d  at  once  under  the  best  hygienic  conditions. 

Warmth  essential.     Water  to  drink  in  sips.     Turpentine  stupes  to 
abdomen.     \o  food  during  acute  attack.     Hot,   strong  cofifee,   good. 
Rogers'  method. 

Calcium  permanganate  water  (gr.  i  to  vi  to  a  pint)  ad  lib. 
Permanganate  pills  :  — 
Potassium  permanganate  gr.  ii. 

Kaolin  and  vaseline  as  recjuired. 
To  be  taken  every  ^  hour  for  two  hours,  then  one  pill  half-hourly. 


210  DISEASES   DUE   TO    BACTERIA 

Those  vomited  being  replaced.     Continue  until  the  stools  are  green 
and  less  copious,  which  can  be  expected  in  twelve  to  twenty-four  hours. 

In  mild  cases  give  one  four-hourly,  in  severe  continue  as  above. 

Pills  old  and  hard  are  useless. 

In  collapse,  hot  bottles  and  when  pulse  fails  open  median  basilic 
vein  with  Rogers'  special  silver  cannula  inserted  and  hypertonic 
saline  solution  given  until  B.P.  returns. 

Sodium  chloride  gr.  cxx. 

Calcium  chloride  gr.  iv. 

Potassium  chloride  gr.  vi. 

Water  to  a  pint. 

Boil  for   15  minutes  to  sterilize. 

Inject  at  a  temperature  varied  according  to  rectal  temperature. 

Rectal  temperature  Saline  injection 
99°  F.  over  98 '4°  F. 

98°  F.  100^-102°  F. 

100°  F.  97' 5°  F. 

102°  F.  and  over  Warm 

If  blood  pressure  falls  below  70  mm.  of  Hg  give  intravenous  saline 
at  once.  Give  it  in  cases  of  restlessness,  cyanosis,  cramps,  black  blood 
as  shown  by  pin  prick. 

Stop  the  injection  in  cases  of  respirators  or  other  distress. 

Leave  the  cannula  in  situ  as  it  may  be  needed  to  repeat  the 
injections.     Warm  rectal  injections  can  be  given. 

If  no  severe  cramps,   strychnine  hypodermicallv. 

If  suppression,  dry-cup  over  each  loin. 

In  the  stage  of  reaction  give  :  — 

Bland  foods  and  avoid  meat  extracts  also. 

I^     Bismuth  salicylate         ...         ...         ...         j^r.  xv. 

Soda  bicarbonate  ...         ...         ...         gr.  v. 

Liq.  opii  sedatives  ...         ...         ...         ni  v. 

Mucilage  q.s. 
Chloroform  water  to  5  i. 

5  i  t.d.s. 

For  persistent  vomiting  give  :  — 

(i)  Cocaine  gr.  ^  dissolved  in  5i  of  water. 

(2)  INIist.  pepsini  co.  et  bismuth   10  minims,   half-hourly   for  four 

doses. 

(3)  Two  drops  of  tinct.  iodine  in  water. 

For  cramps  :  massage,  morphia,  inhalations  of  mixture  of  chloro- 
form and  oxygen. 

For  delirium  :   bromides,  with  tincture  of  hyoscyamus. 
For  prostration ;  strychnine  or  camphor  in  ether. 
Watch  for  uraemia. 
Opium  eaters  all  die. 


CHOLERA 


211 


Rogers  gives  some  very  interesting  figures    comparing  the  results 
of  the  old  methods  with  the  new    as  follows  :  — 


Old  System,  1895-1905 
Age  Cases  Deaths      Percent. 


52-8 

51-3 
5&-5 
637 
69-4 

737 


To   5> 
5  to  10 

'ears  \ 

36     . 

•        19 

0  ,,  20 

■)1           '     " 

150     . 

.       80 

0  .,  30 

11           .  -. 

468     . 

.     274 

0  „  40 

,,           .  .. 

273     •• 

•      174 

0  „  50 

,, 

III      .. 

•       77 

)ver  50 

)1           .  .  . 

38     .. 

.       28 

Cases 


24 

121 
197 
134 

43 
23 


New  System,  1913-1915 


Deaths 


17 
44 
28 
16 
1 1 


Reduction 

er  cii  t. 

of 

mortality 

per  cent. 

36-3    } 

0               ( 

6ro 

^33^ 

140 

..    730 

22-3 

64'c 

20-9 

670 

365 

..      47'o 

47-8 

••      35-0 

The  remaining  mortality  was  due  to  collapse,  uraemia,  pneumonia, 
heart  failure  and  exhaustion,   hyperpyrexia,   septic  complications. 

The  total  mortality  is  reduced  by  his  treatment  to  20  per  cent,  or 
one-third  of  the  former  rate. 

Cox  claims  better  results  still  as  a  result  of  using  isotonic  saline 
instead  of  hypertonic  saline.  Cox,  who  has  treated  over  2,000  cases, 
gives  his   figures  as   follows:  — 

India  China 

Collapse  cases  only 


Rogers,  1909-10 
Number  of  cases,  103 
Average  amount  transfused,  4^  pints 
Mortality,  32  per  cent. 


Cox,  1910 
Number  of  cases,  666 
Average  amount  transfused,  13  pints 
Mortality,  i8"8  per  cent. 


In  certain  cases  Cox  gives  hypertonic  saline  for  the  first  eight  pints 
and  then  continues  with  the  isotonic  salines. 

Rogers  denounces  opium  in  any  case. 

Cox  has  found  it  very  useful  in  cases  of  collapse. 

Cox  continues  :  An  adequate  reaction  proportionate  to  the  degree 
of  collapse  must  be  looked  for  and  assisted.  This  condition  is  never 
attained  until  the  infusion  reaction  rigor  (which  occurs  approximately 
when  five  pints  have  been  infused)  is  w^ell  passed.  The  continuance 
of  the  saline  infusion  after  the  occurrence  of  the  reaction  rigor  up  to 
8-10  pints  will  procure  the  following  benefits  :  — 

(i)  Dilution  of  the  blood. 

(2)  Elevation  of  the  blood  pressure,  with  re-establishment  of  sup- 
pressed renal  flow^ 

(3)  Elimination  of  the  endotoxins  from  the  blood  and  later  from  the 
stools,  thus  obviating  the  onset  of  the  febrile  reaction  stage  of 
cholera,  the  remainder  of  the  illness  being  usually  apyrexial. 

No  apprehension  need  be  felt  at  a  rise  of  temperature  to  103°  F. 
during  the  infusion,  in  fact,  this  degree  of  temperature  oscillation  I 
consider  the  most  favourable  for  cessation  of  infusion  of  less  than  six 


212  DISEASES   DUE   TO    BACTERIA 

pints;  the  temperature  of  the  saHne  in  the  cistern  should  be  loAvered 
and  the  infusion  continued. 

That  the  reaction  induced  by  the  saline  infusion  may,  to  some 
extent,  be  due  to  a  toxaemia  induced  by  the  endotoxins  of  water-borne 
bacilli  used  in  the  infusion  is  possible;  that  it  entirely  accounts  for  the 
reaction  rigor  I  do  not  believe.  In  any  case,  it  will  be  interesting  to 
see  to  what  extent  the  phenomena  of  the  infusion  reaction  will  be 
modified  by  filtration  previous  to  boiling. 

PROPHYLAXIS   (Castellani). 

(7)  Public. 

(i)  Protection  of  the  frontiers,  regular  inspection,  quarantine 
stations. 

(2)  A  central  Cholera  Board,  with  a  full  staff  and  apparatus  for 
bacteriological  work,   disinfection,   &c. 

(3)  Instruction  of  the  populace  by  pamphlets. 

(4)  House-to-house  search  for  cases. 

(5)  Search  for  carriers  and  sources  of  infection. 

(6)  Distribution  of  medicines  and  disinfectants. 

(7)  Provision  of  medical  aid  to  be  readily  obtained  by  all. 

(8)  Crusade  against  house-flies. 
(77)  Private. 

(i)  Personal  cleanliness. 

(2)  Avoidance  of  foods  liable  to  be  contaminated. 

(3)  Avoidance  of  foods  liable  to  cause  diarrhoea. 

(4)  Filtration  and  boiling  of  all  water  for  drinking  and  cooking. 
The   regular  cleansing  of  all   filters  and  water  receptacles. 

(5)  Boiling  of  milk  and  protection  against  flies. 

(6)  Clean  sanitary  dwellings. 

(7)  Anti-cholera  vaccination.  Hafifkine's  protects  for  six  to  four- 
teen months. 

(8)  Immediate  application  for  medical  aid  in  the  event  of  any 
diarrhoeal    illness. 

Professor  Simpson,  working  at  Calcutta,  was  inoculating  some 
civilians  with  Hafifkine's  vaccine  of  living  cultures,  when  an  epidemic 
broke  out  four  days  afterwards  with  the  following  interesting 
results  :  — 

The  654  uninoculated  had  71  deaths,  or  io"86  per  cent. 

The  412  inoculated  had  12  deaths,  or  2*99  per  cent. 

Not  only  so,  but  for  the  ensuing  twelve  months  the  inoculated  were 
almost  free  from  the  disease,  while  cases  were  cropping  up  all  the  time 
among  the  uninoculated,  the  ratio  of  the  mortality  being  as  3  is  to  1 1 . 

Kitasato  in  Japan,  and  Castellani  in  Ceylon,  used  devitalized 
vaccines,  but  Simpson  used  living  cultures. 


ENTERIC  FEVER  IN  THE  TROPICS  213 

During  the  Balkan  War,  1913,  Greece  used  devitalized  vaccines 
with  interesting  results  :  — 

Those  with  two  vaccinations,  91,224  soldiers  had  644  cases,  or 
1-1,000. 

Those  with  one  vaccination,  14,613  soldiers  had  618  cases,  or 
42-1,000. 

The  non-inoculated,  8,968  soldiers  had  834  cases,  or  93-1,000. 

Those  not  vaccinated  had  fourteen  times  more  cholera  cases  than 
those  vaccinated  twice. 

When  the  vaccinations  were  completed  cholera  disappeared  as  if 
by  enchantment,  sporadic  cases  only  arising  from  newly  arrived,  non- 
inoculated  soldiers. 

Equally  good  results  were  obtained  from  the  civil  population. 

One  has  to  remember  that  the  type  of  the  disease  was  not  a  very 
virulent  one.  Epidemics  of  cholera  vary  much  in  their  mortality  from 
90  to  20  per  cent. 

Carriers  are  always  troublesome.  A  convalescent  may  carry  the 
vibrios  for  three  weeks,  some  up  to  one  year.  The  stools  should  be  free 
on  two  examinations  before  the  patient  is  discharged.  At  present  there 
is  no  satisfactory  way  of  clearing  them  out  of  the  gall-bladder. 

ENTERIC  FEVER  IX  THE  TROPICS. 
DEFINITION. 

A  specific  infectious  fever,  three  varieties  caused  by  :  — 
(i)  Bacillus  typhosus  (Ebert)  causes  typical  typhoid  fever. 

(2)  Bacillus  paratyphosus  A  causes  paratyphoid  fever  A. 

(3)  Bacillus  paratyphosus  B  causes  paratyphoid  fever  B  accom- 
panied by  diarrhoea,  pea-soup  stools,  rose  coloured  rash  and 
running  a  prolonged  course  of  about  21  davs. 

Typhoid  fever  has  long  existed  in  the  tropics  but  was  previously 
concealed  under  the  term  of  "  remittent  fever,"  &c.  It  is  now  well- 
known  to  exist  in  many  if  not  most  tropical  countries,  occurring  in 
Europeans  and  natives.  It  is  alarminglv  prevalent  among  young 
soldiers  and  civilians  in  the  East,  especiallv  during  their  first  three 
years'  residence. 

AETIOLOGY. 

Caused  by  the  above  organisms. 

It  attacks  both  sexes  usually  between  15  and  25  years,  but  no  age 
is  exempt. 

Infection  is  conveved  bv  :  — 

(i)  Contaminated  water,  ice  or  milk. 

(2)  Foods  contaminated  by  flies. 


214  DISEASES   DUE   TO    BACTERIA 

(3)  Uncooked  vegetables  grown  on  infected  soils. 

(4)  Shell-fish  groAvn  on  polluted  beds. 

(5)  Direct  contact  with  the  soiled  linen,  stools  and  urine,  typhoid 
abscesses  of  the  patient. 

(6)  Contaminated  soil  resulting  from  defective  drains  and  cess- 
pools. The  soil  may  be  dry  and  be  blown  on  to  food  or 
swallowed  in  the  dust. 

(7)  Typhoid  carriers. 

(1)  F^CAL  CARRIERS. 

The  proportion  of  female  carriers  to  the  male  is  as  five  to  one. 

As  women  have  gall-stones  more  frequently  than  men,  and  as  the 
gall  bladder  is  a  habitat  of  the  typhoid  bacillus  it  is  not  tO'  be  wondered 
at  that  symptoms  of  gall-stones  occur  in  14  per  cent,  of  cases  after 
enteric  fever.  The  bacilli  may  be  passed  down  the  gall  bladder  to  the 
intestines  and  expelled  in  the  faeces  without  the  patient  being 
obviously  ill,  yet  such  bacilli  may  be  very  virulent  and  cause  death  to 
persons  infected  by  them.  The  discharge  of  the  bacilli  appears  to  be 
intermittent.  It  is  stated  that  women  are  more  commonly  carriers 
than  men  because  their  resisting  powers  are  reduced  by  the  decrease 
in  the  alexins  of  the  blood  during  the  menstrual  and  puerperal  periods. 

(2)  FLY  CARRIERS. 

Infection  by  the  house-fly  (Musca  domestica)  and  the  fruit-fly 
(Drosophila  ampelaphila)  is  most  important  because  the  fly  takes  up 
the  bacilli  into  the  alimentary  canal  in  which  the  bacilli  increase  in 
number  and  virulence.     (See  habitats  of  house-fly,  &c.,  p.  224.) 

The  fly  is  a  known  foul  feeder.  After  settling  on  fcecal  material  it 
goes  on  to  human  food,  regurgitates  a  little  fluid  from  its  crop  to 
dissolve  the  food  substances  and  thus  infects  them.  It  also  defc-ecates 
frequently.  The  term  "autumnal  fever"  has  been  given  to  epidemics 
which  are  in  the  time  of  the  greatest  prevalence  of  the  flies. 

(3)  URINARY  CARRIERS. 

In  such  cases  the  habitat  is  the  renal  pelvis  which  is  usually 
chronically  inflamed.  It  may  also  live  in  the  urinary  bladder  and 
other  processes  of  the  urinary  tract.  The  bacilli  pass  directly  into  the 
urinary  stream  and  are  thus  excreted. 

F^cal  and  urinary  carriers  may  infect  directly  the  air,  food,  food 
utensils,  drinking  water  and  fomites,  which  in  turn  infect  the  victim. 

B.  paratyphosus  B,  commonly  met  with  in  luirope,  lives  often  in 
the  gall  bladder  and  infects  the  faeces.  It  has  not  been  found  in  the 
urine.     It  has  been  found  in  the  common  house-fly. 


ENTERIC  FEVER  IN  THE  TROPICS  215 

B.  paratyphosus  A  is  prevalent  in  India  and  China.  Several  out- 
breaks have  been  traced  to  fecal  contamination. 

Epidemics  may  be  due  to  the  seasonal  prevalence  of  flies,  distribu- 
tion of  milk,  an  infected  well  or  stream,  the  seasonal  use  of  shell-fish, 
eating  of  fried  lish  so  common  in  the  East  End  of  London. 

For  a  description  of  the  typhosus  bacillus,  see  p.  619. 

Europeans  newly  entering  the  tropics  should  be  particularly 
careful.  In  Bengal  50  per  cent,  of  the  cases  in  Europeans  occurred 
within  one  year  of  their  arrival  from  Europe. 

Rogers  noticed  that  in  India  41  "67  per  cent,  of  the  cases  were  in 
children  under  15  years  of  age. 

Natives  are  asserted  to  be  somewhat  immune  to  the  disease. 

Roberts  in  explaining  this  gives  some  interesting  comparisons. 

The  gut  of  the  native  is  longer,  more  muscular  and  thicker  than 
that  of  the  European,  also  Fever's  patches  are  less  in  evidence. 

Habitat  and  diet  also  are  important  predisposing  factors. 

The  Native  The  European 


Food  cold  and  dry. 

Bulky,  coarse,  much  waste. 

Vegetable  grains,  cereals,  pulses  ;  large 
cellulose  content  ;  low  protein  and  fat 
content. 

Food  partially  cooked,  plain  and 
monotonous. 

Meals  infrequent,  twice  daily,  long 
fasts. 

Mastication  generally  good. 

Life  and  work  in  the  open  air. 

Fascal  evacuations  twice  daily,  large, 
10-12  ounces. 

Strain  on  stomach  and  large  bowel. 

The  majority  eat  to  live. 


Hot  and  fluid. 
Concentrated  and  soluble. 
Animal  food,  with  high  protein  and  fat 
content. 

Thoroughly  cooked,    well   mixed,  and 
varied. 

Meals  frequent,  4-5  daily. 

Faulty  in  the  extreme. 
Sedentary  and  indoors. 
Small,    5-6   ounces,  constipation  com 
mon,  purgatives. 

Strain  on  stomach  and  small  intestine 
More  live  to  eat. 


PATHOLOGY. 

The  disease  is  a  septicemia  produced  by  the  invasion  of  the 
intestinal  lymphoid  tissue  by  bacilli  which  have  entered  by  the  mouth. 
In  this  tissue  the}'  multiply,  many  passing  bv  the  lymphatics  to  the 
abdominal  l}-mphatic  glands  and  the  spleen  increasing  rapidlv  in 
each.  In  the  blood  they  are  destroyed  if  few  in  number  and  their 
toxins  neutralized.  If  it  does  not  proceed  beyond  this  an  ambulatory 
or  abortive  attack  is  produced. 

When  the  bacilli  are  more  numerous  but  destroyed  bv  bacteriolysis 
there  may  not  be  sufficient  antitoxin  to  neutralize  their  toxins,  then  the 
fever  begins.  Ferhaps  the  antitoxin  is  formed  irregularly  and  so 
accounts  for  the  intermittent  nature  of  the  disease  and  the  relapse  in 
the  tropics.  The  endotoxin  causes  the  endothelial  cells  to  swell  so 
that  the  small  lymph  channels  in  the  liver  are  blocked  and  patches  of 
focal  necrosis  formed. 


2i6  DISEASES   DUE    TO    BACTERIA 

While  the  bacilli  may  be  found  in  any  part  of  the  body  they 
prefer  the  lymphatic  tissue.  When  a  clump  blocks  a  cutaneous 
lymphatic  a  rose-coloured  macular  papule  appears  which  explains  the 
characteristic  rash. 

Autoinfection  may  possibly  explain  some  cases  of  second  and  third 
attacks,  the  bacilli  of  the  gall-bladder  or  other  habitat  injecting  anew 
the  general  system  of  the  patient. 

The  gradual  onset  is  the  result  possibly  of  the  struggle  between 
the  antitoxins  and  the  bacterial  toxins.  The  rare  sudden  onset  may  be 
due  to  lowered  resistance  of  the  patient. 

Immunity  is  partial,  sometimes  complete  for  the  particular  bacilli 
causing  the  attack,  but  not  against  other  varieties. 

P.M. 

Bowels  distended  with  gas.  Marked  congestion  of  the  mucous 
membrane  about  ileo-ca?cal  junction. 

Mesenteric  glands  enlarged  and  congested. 

Spleen  and  at  times  the  liver  also  enlarged  and  congested.  The 
former  is  friable  and  dark  red  in  colour. 

Perforation  may  be  found. 

The  heart  soft,  flabby  and  friable. 

The  voluntary  muscles  undergo  granular  degeneration. 

Peyer's  patches  are  affected  according  to  the  stage  reached. 

First  Week : — 

Swelling,  the  result  of  leucocytic  infiltration.  The  submucous 
coat  is  also  involved,  and  sometimes  the  muscular  coat. 

Second   Week : — 

Sloughing,  the  surfaces  are  abraded,  the  sloughs  are  bile-stained. 

Third  Week  ; —    . 

Separation,  the  sloughs  come  away,  leaving  an  ulcerated  surface, 
with  undermined  edges  in  the  long  axis  of  the  bowel  having  its  base 
of  muscularis  mucosae,  infiltrated  mucosa  or  peritoneum. 

Fourth  Week : — 

Scarring,  the  ulcers  granulate  up,  the  scar  forming  and  contracting. 

The  solitary  glands  may  pass  through  the  same  process. 

The  ileum  and  jejunum  are  usually  affected. 

The  bile  is  usually  light  coloured,  watery,  but  may  be  inspissated. 

Kidneys  enlarged,  both  cortex  and  medulla  congested,  fatty 
degeneration,  rarely  small  abscesses. 

There  may  be  an  inflammatory  condition  of  part  or  whole  of  the 
respiratory  tract.  H^emorrhagic  infarcts,  py^emic  abscesses  and  puru- 
lent infarcts  may  be  seen.     Venous  thrombosis  is  not  uncommon. 

The  bone  marrow  is  generally  congested. 


ENTERIC  FEJ'ER  IN  THE  TROPICS  217 

Arthritis  of  joints  and  abscesses  in  various  parts;  sequelae  may  be 
found. 

SYMPTOMATOLOGY. 

Incubation  three  to  twenty-three  days,  average  ten  days. 

Onset  insidious,  headache,  sometimes  epistaxis,  increasing  weak- 
ness. 

As  the  condition  is  a  septiccemia  any  part  may  be  affected,  causing 
pleurisy,  vomiting,  or  other  symptoms  tending  to  obscure  the 
diagnosis. 

The  disease  is  usually  ushered  in  by  some  other  fever,  as  malaria. 

First  Week : — 

The  tciuperatiire  rises  "  staircase  "  manner,  going  up  two  degrees 
in  the  evening  and  falling  one  degree  in  the  morning  (not  always)  up 
to  about  104°  F. 

The  pulse  is  slow  and  often  dicrotic. 

The  skin. — Cheeks  flushed.  Skin  hot  and  dry,  sometimes  inter- 
mittent sweating.  A  bluish  mottling  on  abdominal  wall.  Often 
yellow  coloration  of  palms  and  soles. 

The  tongue. — White  moist  fur  on  dorsinn,  tip  and  edges  are  red. 
Mouth  dr}',  thirst  marked. 

The  abdomen  is  distended,  tenderness  in  the  right  iliac  fossa,  and 
spleen  is  enlarged.  Abdominal  reflex  is  diminished  or  lost.  Vague 
general  pains. 

Exhaustion  increases,  patient  becomes  apathetic,  drowsy,  eyes 
bright;  sleeplessness  and  vomiting  are  not  uncommon. 

The  stools. — Diarrluva  in  20  per  cent,  of  cases,  becomes  ochre- 
yellow  (pea-soup)  in  appearance,  but  the  bowels  mav  be  confined 
throughout. 

Bacilli  may  be  cultivated  from  the  blood,  but  specific  agglutination 
is  not  available. 

Second   Week : — 

The  symptoms  above  are  aggravated,  but  headache  ma}^  disappear. 

The  temperature  remains  high.     Mild  delirium   is  not  uncommon. 

Rash  appears  from  seventh  to  twelfth  dav  in  70  per  cent,  of  cases 
on  abdomen  or  chest  in  crops;  arms  and  legs  may  also  be  affected. 
The  isolated  maculopapules  which  disappear  on  pressure  are  slightly 
elevated,  rose-red,  4  mm.  in  diameter,  last  three  to  five  days,  leave 
a  yellow  stain.     They  may  continue  to  end  of  third  week. 

Tendency  to  hagmorrhage  (10  per  cent,  of  cases)  is  marked,  and 
danger  of  bowel  perforation  possible. 

The  specific  agglutination  reaction  may  now  be  obtained. 

The  diazo-reaction  of  the  urine  is  now  also  possible. 


2i8  DISEASES   DUE   TO    BACTERIA 

The  bacilli  are  not  so  numerous  in  the  peripheral  circulation,  but 
more  plentiful  in  the  spleen,  fasces,  urine  {33  per  cent,  of  cases),  and 
rose  spots. 

Liver  and  gall-bladder  symptoms  may  set  in. 

B.P.  diminished,  dicrotism  perhaps  has  disappeared. 

Cold  extremities.     Vomiting  rare. 

The  typhoid  state  may  set  in,  lips  and  teeth  being  covered  ^ith 
dark  brown  scales  (sordes),  tongue  dry,  furred,  fissured,  pharynx 
inflamed  or  ulcerated.  More  or  less  meteorism  always  present,  and 
may  be  very  troublesome.  Reduction  in  red  cells,  Hb.  and  leucocytes 
shown,  but  the  mononuclear  leucocytes  are  increased.  Coagulability 
of  blood  reduced. 

Third   Week : — 

Temperature  falls  by  lysis  to  normal  about  the  twenty-first  day,  and 
with  this  symptoms  may  subside  and  convalescence  begin.  In  some 
cases  profound  symptoms  may  appear.  The  heart  is  weak  and  rapid. 
The  lungs  congested,  fatal.  Epistaxis  possible.  Perforation  not 
uncommon  (3  per  cent,  of  cases).  Subsiltus  tendinum  often  present. 
Emaciation  increases.  Liver  dulness  encroached  upon  by  the  tym- 
panites and  breathing  becomes  thoracic.  LTrine  may  be  suppressed. 
Peritonitis  or  collapse  may  cause  death. 

Fourth   Week : — 

Temperature  becomes  normal;  convalescence  begins. 

Watch  for  relapses. 

In  severe  cases  the  status  typhosus  may  continue;  the  heart  may 
fail,  for  the  myocarditis  is  considerable. 

The  varieties  are  according  to^  the  severity  of  the  symptoms,  am- 
bulatory, abortive,  mild,  typical,  severe  and  masked.  H^emorrhagic 
cases  have  been  known,  when  there  has  been  bleeding  from  the  mucous 
membrane,  tongue,  gums,  bladder  and  intestines,  also  purpuric 
eruptions. 

In  Ceylon  the  disease  caused  by  B.  paratyphosus,  viz..  Paratyphoid 
fever,  is  indistinguishable  from  Typhoid  fever,  though  it  generally 
runs  a  milder  course.  The  intestinal  ulcers  are  identical  with  those  of 
typhoid.     Cases  of  mixed  infection  are  not  rare. 

COMPLICATIONS. 

Malaria  very  important. 

Haemorrhage  from  bowel,   nose  and  mucous  surfaces. 

Perforation  mav  occur  in  mild  cases. 

Peritonitis,  with  or  without  perforation. 


ENTERIC  FEVER  IN  THE  TROPICS  219 

]\Ieteorism  or  tympanitis. 

Thrombosis,   usual  of  femoral  vein,   embolism  possible. 

Xeuritis,  bronchitis  and  pneumonia, 

Earlv  tvphoid  state  or  cardiac  failure. 

Bed  sores  and  boils.     Alopecia. 

Tvphoidal  arthritis,  typhoidal  spondylitis,  ascending  myelitis. 

Periostitis.     Inflammation   of   thyroid.     Iritis,    orbital   cellulitis. 

Relapses  during  the  third  and  fourth  week  after  the  temperature  has 
been  normal  are  not  uncommon. 

Signs  of  perforation. — Sudden  and  severe  pain,  rapid  and  extreme 
distension  of  the  abdomen,  absence  of  abdominal  respiration,  tympanic 
percussion  note,  absence  of  hepatic  and  splenic  dulness.  Shock,  rapid 
pulse  and  respiration,  fluid  in  abdomen.     Collapse. 

DIAGNOSIS. 

In  typical  cases  easy.  The  insidious  onset,  dicrotic  pulse,  medium 
enlargement  of  spleen,  rose  rash,  leucopenia;  if  all  are  present  it 
scarcely  permits  of  mistake. 

In  the  tropics  the  course  is  more  often  atypical. 

Malarial  fever  \\ill  modify  the  temperature  chart,  alter  the  appear- 
ance of  the  rash,  and  easily  throw  one  off  his  guard. 

Bacteriological  diagnosis  is  therefore  all-important,  as  seen  in  :  — 

(i)  The  agglutination  test  (Widal).     Important.     See  p.  611. 

(2)  Hfemocultures.     Important.     See  p.  623. 

(3)  The  bacilli  in  the  stools  and  urine. 

(4)  Spleen  puncture  gives  good  results,  but  should  not  be  a  routine 

procedure. 
{5)  Ophthalmo-reaction    and    cuti-reaction,    similar    as    for    tuber- 
culosis. 

(6)  Subcutaneous  inoculation  of  dead  cultures  and  \^incent's  splenic 

diagnosis. 

(7)  Complement  fixation. 

With  regard  to  the  ]]^idal  reaction  (see  p.  611),  the  three  strains  of 
bacilli  should  each  be  tried  failing  agglutination  of  one  of  them. 

It  is  absent  during  the  first  week  in  any  case,  and  may  be  in  excep- 
tional cases  during  the  whole  period.  On  the  contrary,  if  a  positive 
result  is  obtained,  one  must  remember  that  a  former  attack  would  give 
it  for  months  or  years  after  it  was  over.  It  may  be  possible  in  vac- 
cinated persons. 

It  has  been  found  present  in  jaundice,  Weil's  disease,  and  puerperal 
fever. 

The  rapid  differentiation  of  the  bacilli  of  the  typhoid  group  by 
means  of  test  papers  has  been  devised  by  Hollande  and  Beuverie. 


220  DISEASES   DUE   TO    BACTERIA 

For  the  differentiation  of  the  Bacillus  typhosus,  B.  paratjphosus  A 
and  B  and  B.  coli  four  test  papers  are  used  as  follows  :  — 

(i)  A  piece  of  filter  paper  is  dipped  into  a  i  per  cent,  solution  of 
silver  nitrate,  and  is  then  quickly  dried;  it  is  then  dipped  intO' 
a  lo  per  cent,  solution  of  collodion  in  equal  parts  of  alcohol 
and  ether,  drained  and  dried  in  the  dark. 

(2)  A  filter  paper  is  dipped  into  a  i  per  cent,  solution  of  neutral  red 

containing  10  per  cent,  glucose,  and  then  dried  and  impreg- 
nated with  collodion  as  before. 

(3)  A  filter  paper  is  dipped  into  a  10  per  cent,  solution  of  lead  sub- 

acetic  and  dried,  as  before,  with  collodion. 

(4)  A  paper  is  dipped  into  the  following  solution  :  o'z  grm.  litmus,. 

4'o  grm.  neutral  sodium  phosphate,  5'o  grm.  lactose,  I'o  grm. 

sodium  bicarbonate,  50  c.c.  distilled  water;  it  is  then  dried  and' 

again  treated  Avith  collodion. 
Portions  of  these  prepared  papers  are  then   dropped  into  peptone' 
broth  tubes,  which  are  then  autoclaved  at  118°  C.  for  twenty  minutes. 
Results. 
(i)  With  the  silver  nitrate  paper  a  growth  of  B.  coli  is  obtained' 

in  about  twelve  hours,  of  the  three  other  bacteria  in  about  two- 

to  three  days. 

(2)  With  the  neutral   red  paper,   the  red  colour  of  the  paper  and' 

broth  are  unchanged  by  B.  typhosus,  the  paper  remains  at 
the  bottom  of  the  tube,  and  there  is  no  gas  formation. 

With  the  three  other  organisms  the  colour  changes  to 
canary-yellow,  and  gas  is  formed  between  the  collodion  and' 
the  paper,  and  the  latter  then  flloats  to  the  surface. 

(3)  Lead  acetate  paper  is  blackened  after  about  twentv  hours,  except 

in  the  case  of  B.  paratyphosus  A,  in  which  no  change  occurs. 

(4)  With  the  litmus  lactose  paper  the  lilac  colour  of  the  paper  and 

broth  is  discharged  after  about  twenty  hours,  but  in  three  days 
the  colour  returns  in  the  case  of  B.  paratyphosus  B. 

In  using  hcprnocultures  there  are  two  methods  :  — 

(i)  Dilution  method. 

Take  2*5  c.c.  of  blood  from  the  median  basilic  asepticallv,  drop  it 
into  a  large  sterile  flask  at  once  containing  200  to  300  c.c.  of  faintlv 
alkaline  broth. 

Incubate  at  37°  C. 

In  twelve  to  twenty-four  hours,  in  positive  cases,  the  broth  becomes- 
cloudy  and  shows  a  germ  growth.     Then  test  this  in  various  media. 

The  agglutination  test  should  also  be  done. 

(2)  Bile  enrichment  method. 

Take  blood  as  above  or  from  the  finger  tip. 


ENTERIC  EEVER  IN  THE  TROPICS  221 

Drop  il  into  a  mixture  of  oxbile  90  c.c,  glycerine  10  c.c,  and  pep- 
tone 2  grm.,  distributed  into  small  flasks  each  containing  20  c.c.  of 
the  medium. 

Incubate  and  test  as  above. 

Ehrlich  and  Diazo  Reaction. 

Generally  present  in  typhoid  during  the  second  and  third  week. 

It  may  be  absent  in  very  mild  cases. 

V^ery  active  tuberculosis  gives  it  fairly  constantly. 

jMeasles  gives  it  more  frequently  than  German  measles. 

If  it  is  present  it  is  not  diagnostic  of  typhoid,  but  may  be  used  for 
confirmation,  especially  if  the  other  diseases  can  be  excluded. 

Prepare  two  fresh  solutions:  — 

(i)  A  saturated  solution  of  sulphanilic  acid  in  5  per  cent.  HCl. 

(2)  A  2|-  per  cent,  solution  of  sodium  nitrite. 

To  5  c.c.  of  urine,  add  an  ecjual  cjuantity  of  solution. 

(i)  Then  add  a  few  drops  of  solution  (2)  and  shake  till  frothy. 

Add  ammonia  till  alkaline. 

If  the  liquid  is  port-wine  colour  and  the  froth  is  red,  the  reaction  is 
positive. 

In  examining  the  f^ces  use  Conradi-Drigalski  medium. 

The  malachite  green  solution  inhibits  the  coli  growth  and  permits 
that  of  the  typhoid  bacillus. 

In  examining  water,  pass  it  through  a  filter;  the  organisms  remain 
on  the  filter  candle;  brush  these  off  into  the  above  medium. 

Alum  will  bring  down  a  precipitate  entangling  the  organisms,  which 
can  then  be  treated  as  above. 

The  typhoid  bacillus  is  seldom  found  in  the  water  that  has  caused 
the  disease,  because  fourteen  days  have  elapsed  since  the  patient  par- 
took of  it  and  the  organisms  would  have  gone. 

DIFFERENTIAL  DIAGNOSIS. 

In  malaria,  examine  the  blood  for  the  parasites. 

In  relapsing  fever,  the  onset  is  sudden  and  the  blood  will  show  the 
parasite. 

In  undulant  fever,  do  an  agglutination  test;  cumulative  evidence  is 
important. 

In  yellow  fever  by  sudden  onset,  albuminuria  and  black  vomit. 

In  typhus  fever  by  sudden  onset,  mental  symptoms  appear  early. 

In  acute  miliary  tuberculosis,  irregular  fever,  pulse  and  respiration 
rapid,  and  is  not  dicrotic. 

In  psittacosis,  the  specific  bacilli  can  be  isolated  from  the  blood 
and  sick  parrots  will  be  about. 

In  ulcerative  endocarditis,  by  the  murmurs  and  bacteriological 
examination. 


222  DISEASES   DUE    TO    BACTERIA 

In  paratyphoid  fever  A  and  B  the  aggkitination  test  and  cultural 
characteristics  have  to  be  relied  on. 

One  must  not  forget  that  typhoid  and  another  disease  may  co-exist. 
The  mortality  in  the  tropics  is  about  20-25  per  cent. 

TREATMENT. 

(i)  General  management. 

Patient  to  be  put  on  a  wire-woven  mattress  with  a  soft  horsehair 
mattress  placed  upon  it,  two  blankets,  then  the  sheet  with  a  draw  sheet, 
and  its  waterproof  covering  in  the  centre. 

A  mosquito  net  must  be  provided. 

The  room  must  be  large,  as  empty  as  possible,  and  well  ventilated. 

All  motions  and  urine  and  fomites  sterilized  at  once  in  carbolic. 

A  day  and  a  night  nurse  well  skilled  and  vaccinated  are  essential. 

The  patient  to  be  sponged  all  over  twice  daily  with  tepid  water. 

Gently  rub  irritated  parts  with  rectified  spirits,  and  then  dust  with 
boric  or  starch  powder. 

Mouthwash  necessary.     Bed  pan  and  urine  bottle  to  be  used  all  the 
time. 

(2)  Diet. 

No  solid  food  is  the  safest  rule. 

Milk,  beef-tea,  chicken  broth,  albumin  water  from  white  of  eggs. 
Plasmon,  barley  water,  malted  milk,  whey,  junket  and  weak  tea. 
Water  ad  lib.,  neither  hot  nor  cold. 

(3)  Drugs. 

The  less  the  better  as  a  rule.     Simple  enema  for  constipation. 
Urotropine  gr.  x  t.d.s.  in  second  week  to  disinfect  urinary  tract. 

(4)  Serotherapy. 

Chantemesse's  anti-typhoid  serum  has  good  results. 

The  Wright-Leishman's  vaccine  from  forty-eight  hours  culture,  irr 
three  doses  500  millions  of  bacilli,  ten  days  later  1,000  million,  ten  days 
later  another  1,000  million.     This  is  used  as  a  prophylactic. 

Leishman  had  19,000  cases  under  observation  in  India  with  the 
following  results  :  — 

9,000  were  inoculated.  Case  incidence,  5*3  per  cent.  Case 
mortality,  9  per  cent. 

10,000  were  not  inoculated.  Case  incidence,  30*4  per  cent.  Case 
mortality,   17  per  cent. 

The  immunity  lasts  about  one  year.  If  the  whole  Indian  army  was 
inoculated,  1,000  cases  of  enteric  fever  and  200  deaths  would  be  avoided 
each  year. 

Mixed  vaccines  can  be  obtained  for  the  three  stains. 


FLIES   ASL)   DISEASE  22^ 

SPECIAL  SYMPTOMS. 

(i)  Tympanitis.  Fomentations,  turpentine  stupes,  turpentine 
15  minims  every  three  hours.  Hypodermic  injection  of 
eserine  gr.  sV . 

(2)  Hcemorrhage.     Stop  aU  food,   drink  sips  of  water  only,   rice- 

bag  to  abdomen,  raise  bedclothes  on  a  cradle.     Give  simple 
enema.     Morphia  useful  if  one  is  sure  that  perforation  has 
not  occurred. 
Calcium  lactate  gr.  xv  t.d.s.     Lead  acetate. 

(3)  Perforation.     Laparotomy  as  soon   as   possible.      Salines   per 

rectum,  2-6  litres  per  diem  for  a  week. 

(4)  Diarrhoea.     Tannalbin  gr.  x-xii  t.d.s. 

An  enema  with  gr.  v  of  Dover's  powder  also. 
Avoid  bismuth,  as  it  obscures  traces  of  blood. 

(5)  Cholecystitis.     Urotropine  gr.  x  t.d.s.,   anti-typhoidal  vaccina- 

tion or  surgical  treatment. 

(6)  Hyperpyrexia.     Sponging,    bath    immersion    75°-85°    F.     No- 

antipyretics. 

(7)  Delirium.     Bromides,  lumbar  puncture. 

(8)  Cardiac  failure.     Digitalis   and   its  preparations,    or  camphor 

and  ether,  strychnine  and  salines, 
(g)  Phlebitis.     Wrap   leg  in   cotton-wool   after  applying  ichthyol 
in  lanoline  (2  per  cent.). 

(10)  Bedsores.     Harden  skin  with  spirit  lotion  and  disinfect  H2O2 

twice  daily;  dust  with  zinc  oxide  powder. 

(11)  Abscesses.     Incise  and  drain. 

(12)  Bone  lesions.     Supports  as  necessary;  operative  treatment. 

FLIES    AND    DISEASE. 
FLIES  ARE  DANGEROUS   TO   HEALTH. 

(i)  By  carrying  pathogenic  organisms  directly  from  infected  matter 
upon  which  they  have  settled  to  a  wound  abrasion,  or  absorbent 
mucous  membrane  surface.  Hence  perhaps  spreading  disease 
as  anthrax,  ophthalmia,  yaws  and  tropical  sore. 

(2)  By  feeding  on  infected  matter  and  then  carrying  that  infection 
by  means  of  regurgitation  or  defiecation  upon  a  receptive  surface 
as  above.  The  germs  passing  through  the  flies'  intestines 
with  undiminished  virulence  or  possibly  multiplying  therein. 
Staphylococcus  pyogenes  and  the  tubercle  bacillus  has  thus  been 
found. 

(3)  By  carrying  the  germs  as  above  and  infecting  the  food  and 
drink  of  man.  Hence  diseases  can  be  disseminated  as  typhoid 
fever  and  cholera,  perhaps  of  infantile  diarrhoea  and  dysentery - 
They  also  carry  the  eggs  of  parasitic  worms. 


22^  DISEASES   DUE   TO    BACTERIA 

(4)  By  blood-sucking  flies  biting  infected  vertebrates  sucking  up 
the  pathogenic  organisms  and  injecting  them  later  into  the  body 
of  a  healthy  individual  as  the  h^emamoeba^  of  malaria,  the 
trypansome  of  sleeping  sickness,  the  filarice  of  filariasis  and  the 
unknown  organism  of  yellow  fever. 

(5)  By  biting  flies  causing  local  irritations  and  thus  predisposing 
tO'  septic  infection. 

(6)  Bv^  the  adult  flies  laying  their  eggs  in  wounds  and  the  natural 
orifices  of  the  body  like  the  green-bo'tle  and  the  notorious  screw- 
worm  fly,  the  larvae  later  burrowing  their  way  into  the  tissues 
and  causing  even  mortal  damage. 

(7)  By  the  flies  laying  eggs  on  the  food  and  the  larv^  damaging  the 
victims'  health  resulting  from  their  presence  in  the  intestine. 

The  ignorant  and  apathetic  slum  population  suffer  most,  especially 
in  crowded  bazaars  and  markets  where  offal  is  plentiful  and  sanitation 
bad. 

HABITS,  &c.,  OF  THE  MUSCA  DOMESTICA  (House-fly). 

Order. — Diptera  (=  with  two  wings). 

Suborder. — Cyclorrapha  (=  a  circle;  =  suture).  The  imago  escapes 
from  the  puparium  through  a  circular  slit  at  the 
anterior  end. 

Section  (2). — G.  schizophora  (=  a  cleft;  =  I  wear).  In  these  adults 
the  frontal  suture  is  always  well  defined. 

Subsection  (i). — Muscoidea. 

Family. — Muscid^e,  including  house-flies  and  tsetse-flies. 

Genus. — Musca  domestica.  Important  in  carrying  typhoid  fever; 
•98  per  cent,  of  flies  infecting  houses  are  Musca  domestica.  These 
common  flies  are  world-wide.  Small,  dull-coloured,  blackish-grey 
thorax,  yellowish  abdomen,  with  a  median  dark  stripe.  Arista 
feathered  dorsally  and  ventrally,  proboscis  soft,  retractile  and  ends  in 
:a  large  fleshy  labella.  The  fourth  longitudinal  vein  bends  forward  at 
an  abrupt  angle  so  as  to  nearly  close  the  first  posterior  cell.  In  the 
female  the  eyes  are  wide  apart,  in  the  male  they  are  set  close  together. 

In  hot  countries  they  breed  all  the  year  round. 

In  cooler  countries  they  breed  summer  and  autumn  and  then  die 
■out  except  for  a  few  sheltered  ones.  These  survivors  and  new  ones 
which  have  hibernated,  emerging  from  pup^e  soon  increase  their  kind 
in  warm  weather. 

The  female  lays  120-150  eggs  in  a  batch  in  any  moist  rubbish  heap, 
stable  sweepings,  vegetable  debris,  house  refuse,  &c.  The  white, 
shiny,  sticky  eggs  hatch  in  twenty-four  hours  in  warm  weather. 

The  larva  or  maggot  is  whitish,  cylindrical,  tapers  anteriorly,  has 
Iwelve  segments  and  a  very  minute  head.     It  has  a  pair  of  large,  black 


FLIES   AND    DISEASE  225 

mandibles  for  tearing  and  burrowing  into  food  material.  At  the  oppo- 
site end  the  main  tracheal  trunks  open  by  three  slits.  It  feeds  on 
decomposing  refuse. 

It  is  full-grown  in  five  days  in  the  tropics,  in  England  one  to  eight 
weeks . 

The  larvct  then  becomes  barrel  shaped,  skin  hard,  becomes  dark  in 
colour,  forms  the  pupa,  this  stage  lasting  about  five  days. 

Period  of  development  in  the  tropics  about  five  days. 

Period  of  development  in  Itngland  about  two  to  ten  weeks. 

An  adult  flv  lives  from  three  to  sixteen  weeks. 

TO  SUPPRESS  THEM. 

House  refuse,  street  sweepings  and  all  rubbish  to  be  burnt  or 
deposited  several  miles  away  from  human  dwellings  and  leeward  of 
prevalent  winds. 

Latrine  refuse  should  be  buried  beyond  reach  of  the  flies. 

Horse  dung  required  for  agricultural  or  other  purposes  should  be 
dumped  at  a  distance,  treated  with  c{uicklime,  moved  about  with  a  fork 
frequently  so  that  the  birds  may  get  at  the  larvae.  Carts  conveying 
refuse  mtist  not  drip  their  contents  on  the  highwa}'.  Some  enemies 
of  the  fly  should  be  encouraged,  as  :  fungi,  e.g.,  Empusa  muscat, 
spiders,  centipedes,  larvae  of  beetles,  ants,  wasps,  toads,  lizards  and 
rats. 

The  use  of  gauze  and  fly-papers  adds  to  one's  comfort  but  are  use- 
less for  suppressing  flies. 

HOW  THEY  INFECT  MAN. 

The  mouth  parts  of  this  fly  are  so  made  that  the}^  cannot  get  solid 
particles  into  their  mouths.  They  taste  all  foods  by  pressing  their  oral 
lobes  upon  them.  If  such  food  is  satisfactory  a  little  fluid  is  regurgi- 
tated on  to  it  from  its  crop  in  the  attempt  to  dissolve  some  of  the  food 
substance  so  that  it  can  jjass  along  the  minute  pseudo-tracheae.  They 
pour  upon  the  substance,  later  eaten  by  man,  numerous  typhoid  bacilli 
from  infected  faeces  and  thus  infect  a  new  victim  by  the  food,  sugar, 
bread,  milk,  meat  or  edge  of  the  cup,  &c.  Not  only  so,  but  they 
defascate  about  fifty  times  in  twenty-four  hours  and  the  typhoid  bacilli 
pass  out  perhaps  in  an  enhanced  condition  of  virulence  and  infect  the 
food  materials,  water  and  utensils  of  the  human  host.  These  were  very 
instrumental  in  spreading  typhoid  fever  during  the  Boer  War,  igoo- 
1902. 

The  blue-bottle  or  blow-flv  is  of  the  same  family  (Genus  Calliphora) 
and  has  similar  morphology  and  life  history. 

The  fruit-fly  Drosophila  ampelophila  is  also  a  musca  with  a  similar 
history. 

15 


SECTION.   III. 
DISEASES  DUE  TO  HELMINTHS. 

GENERAL    REMARKS. 

DISTRIBUTION. 

THEIR    PATHOGENIC    ACTION. 

NOMENCLATURE. 

THE    GROUPING    OF    HELMINTHS. 

I. — Trematodes  Pathogenic  to  Man. 

General  Morphology^  Life-History,  &c. 

Classification. 

The  More  Pathogenic  Varieties. 

Paragonimiasis   (Endemic  H^emoptosis). 

Schistosomiasis. 

II. — Cestodes  Pathogenic  to  Man. 

General  Morphology^  Life-History^  &c. 

Classification. 

The  Pathogenic  Species  Seriatim. 

The  Treatment  of  Tapeworms. 

III. — Nematodes  Pathogenic  to  Man. 

General  Morphology,  &c. 

The  Less  Important  Species. 
Strongyloides  stercoralis. 
Gnathostoma  spinigerum. 

The  Filarid^. 

Historical  Notes. 

FiLARIA    BANCROFTI,'   MORPHOLOGY^    LiFE-HlSTORY,    &C 

The  Diagnosis  of  Microfilaria. 

The  Filariases. 
Distribution. 
Pathology. 
Clinical  Varieties. 

Filarial  Lymphangitis. 

,,         Orchitis  and  Hydrocele. 
,,         Lymphangiectasis. 
,,        Abscesses. 
,,         Phlebectasis. 
,,         Varicose  Lymph  Glands. 
Filarial  Chylous  Extravasations. 
Chyluria  and  Lymphuria. 
Chylous  and  Lymph.atic  Diarrhoea. 
Chylocele  or  Lymphocele. 
Chylous  Ascites. 


DISEASES  DUE  TO  HELMINTHS 


227 


Elephantiasis. 

Clinical  Varieties. 

Elephantiasis  of  the  Leg. 

Scrotum. 

Vulva. 

Breast. 

Arm. 

Scalp. 

Localized  Areas. 

Notes  on  Filarial  Carriers. 

CULEX    FATIGANS. 

Stegomyia  calopus. 

LOASIS. 

Chrysops  dimidiata  and  silacea. 

Calabar  Swellings. 

Volvulosis. 

Dracontiasis. 

Trichocephaliasis. 

Trichiniasis. 

Ascariasis. 

Oxyuriasis. 

Ankylostomiasis. 

THE    MODE    OF    INFECTION    BY    HELMINTHS. 

THE     PRESERVATION    AND    EXAMINATION     OF     HELMINTHS. 

HIRUDINIASIS. 

POROCEPHALOSIS. 


228  DISEASES  DUE  TO  HELMINTHS 


DISEASES    DUE    TO    HELMINTHS. 

GENERAL  REMARKS. 

The  animals  causing  disease  in  man  are  from  three  king-doms, 
viz.  :   Animal,  Protista  or  Intermediate,  and  Vegetable. 

We  are  concerned  here  with  the  former  or  Animal  kingdom,  which 
for  convenience  is  divided  into  the  :  — 

Sub-kingdom  i,  Protozoa,  and  the  Sub-kingdom  2,  Metazoa. 

The  Protozoa  are  dealt  with  in  another  section. 

All  Metazoa  are  multicellular,  free-living,  or  parasitic  animals, 
having  groups  of  cells  to  perform  definite  functions  and  are  sometimes 
referred  to  as  the  Animal  kingdom  in  a  restricted  sense. 

The  parasitic  metazoa  may  be  ectoparasites  as  insects,  mosquitoes, 
&c.,  or  endoparasites  as  helminths. 

The  Metazoa  parasitic  for  man  are  classified  thus  :  — 

Phylum  (i)  Platyhelmia. 
,,        (2)  Nemathchnia. 
,,        (3)  Annulata. 
,,        (4)  Arthropoda. 

In  this  section  we  shall  deal  with  those  Platyhelmia  and  Nemat- 
helmia  pathogenic  to  man.  These  are  principally  to  be  found  among- 
the  Trematodes  (Flukes),  Cestodes  (Tapeworms),  and  Nematodes 
(Threadworms) . 

DISTRIBUTION. 

Some  helminths  are  found  everywhere,  such  as  the  Ascaris 
lumbricoides,  Oxyuris  vermicularis,  Trichocephalus  dispar  and  others. 

Others  are  prevalent  where  dogs  and  sheep  abound,  as  the 
Taenia  echinococcus  in  Australia;  Flukes  are  found  ^hiefl^'  in  Asia, 
Filaria  volvulus  in  West  .Africa,  and  the  Gastrodiscus  in  Assam. 

The  ankylostomes  are  restricted  to  warm  climates  where  the}'  can 
obtain  plenty  of  moisture,  or  to  warm  temperatures  in  other  countries 
in  the  presence  of  moisture  as  in  the  Cornwall  mines. 

Factors  controlling  the  Distribution  (Leiper). 

(i)  General  sanitary  measures  and  personal  hygiene. 

The  latter  measure  thoroughly  carried  out  would  stamp  out 
Oxyuris  in  six  weeks.  The  eggs  are  laid  about  the  buttocks, 
re-infection  taking  place  by  the  eggs  getting  in  the  finger  nails. 

(2)  The  preparation  of  food. 

Trichinosis  is  common  where  fresh-water  lish  and  insufticientlv 
cooked  food  are  eaten. 


GENERAL  REMARKS  229 

(3)  The  disposal  of  excreta. 

Failure  in  this  measure  causes  apparent  epidemics  of  ankylo- 
stomiasis. 

(4)  Religion. 

Taenia  solium  is  carried  in  pork  and  is  practically  unknown  in 
Mohammedan  countries. 

(5)  Temperature. 

If  the  temperature  is  not  sufficiently  high,  ankylostomes  cannot 
develop.  Meteorological  conditions  must  be  favourable  for  the 
growth  and  development  of  the  parasite  and  its  host. 

(6)  The  control  of  the  water  supply. 

The  Guinea-worm  is  commom  where  the  water  in  the  village 
pond  is  used  for  washing  purposes  at  one  side  and  drinking 
purposes  at  the  other.  In  China,  men  defjecate  into  ponds,  the 
fishes  consume  the  excreta,  while  at  the  other  side  are  men  fish- 
ing and  devouring  the  results  of  their  sport,  becoming  infected 
consequentlv  with  Clonorchis. 

(7)  Carriers. 

Soldiers  from  the  Boer  War  came  home  with  bilharzial  haemal- 

uria  and  infected  others  in  England  in  this  way. 

Some  pigmies  from   Central  Africa  came  to  London  bringing 

with  them  Necator  americanus. 
((S)  Domesticated  animals. 

Where  sheep-rearing  is  common,  the  Echinococcus  prevails  as 

in  Australia. 
(9)  The  distribution  of  the  intermediate  host. 

Snails  and  slugs  are  necessary  for  Flukes. 

The     Bothriocephalus  cannot  spread  without  special  species  of 

fish. 

Trematodes  require  an  intermediate  host  for  their  development. 

Theh'  pathogenic  action  varies  according  to : — 

(i)  The  size  of  the  worm  which  may  cause  mechanical  injury  as 
the  Ascaris  when  blocking  ducts,  &c.,  causing  thereby  append- 
icitis,  retention  of  pancreatic  fluid,  &c. 

(2)  The  position  of  the  worm  which  will  alter  the  symptoms  and 
the  seriousness  of  the  infection.  A  paragonimus  in  the  lung, 
a  fluke  in  the  liver,  or  a  hcematobia  in  the  bladder  give  a  more 
\'aried  set  of  symptoms  than  a  Gui'nea-A\()rm  in  the  subcutaneous 
tissue  of  the  leg. 

(3)  The  number  present,  as  when  several  lunibricoides  form  a  coil 
and  cause  intestinal  obstruction. 

(4)  The  condition  of  the  host.     Ascarides  mav   be  harmless   in  a 


230  DISEASES  DUE  TO  HELMINTHS 

healthy  individual,  but  when  in  a  dysenteric  or  typhoid  intestine 
their  presence  is  more  serious. 

(5)  The  bacterial  infection  induced  by  them.  The  Trichuris 
trichiura  is  harmless  in  itself  but  can  introduce  bacteria  into 
the  mucous  membrane  of  the  appendix,  &c.,  and  set  up  an 
inflammatory  condition.  Helminths  are  usually  covered  ex- 
ternally by  bacteria,  and  their  intestines  may  contain  a  most 
extensive  microbic  flora. 

(6)  Their  selective  action.  Ankylostomes  are  always  found  in  the 
small  intestine.  They  will  pass  through  the  skin,  veins,  heart, 
lungs,  bronchi,  trachea,  oesophagus  and  stomach  but  will  not 
rest  anywhere  until  they  have  reached  the  small  intestine. 
Perhaps  there  is  a  special  secretion  there  which  thev  prefer. 
Again,  trematodes  select  out  their  own  special  mollusc.  If 
trematode  embryos  are  placed  in  a  tank  with  various  molluscs 
the  embryos  will  be  attracted  by  one  particular  variety  only. 
They  will  even  prefer  the  fluid  in  which  their  special  mollusc 
has  been  placed  and  removed,  ignoring  all  other  fluids  that  are 
the  same  in  every  other  respect. 

The  condition  produced  may  be  the  result  of  :  — 

A  mechanical  erosion  of  tissue. 

The  absorption  of  food  materials  ingested. 

Toxagmic  poisoning. 

Fibrosis,  eosinophilia,  and  secondary  amemia. 

The  retention  of  essential  glandular  secretion. 

NOMENCLATURE. 

There  has  been  and  is  still  much  confusion  in  the  naming  of 
parasites.  A  close  study  must  be  made  of  the  literature  of  any  sup- 
posed new  species  before  names  are  applied. 

As  a  guide  to  those  who  may  require  them,  a  set  of  rules  has  been 
drawn  up  to  regulate  the  giving  of  names,  and  are  known  as  :  — 

The  International  Rules  of  Xonicncldturc. 
(i)  The  Language  Rule. 

The  scientific  names  of  animals  must  be  Latin  or  latinized,  or 

treated  as  such. 

The  generic  name  has  a  capital,  the  specific  name  a  small  letter. 

The  generic  name  must  be  one  word  and  used  in  the  singular. 

The    sub-genus,    when    one    is    present,     can     be     inserted     in 

brackets,  with  a  capital  letter  between  the  genus  and  the  specific 

name. 

The   family   name  ends   in   "  Idx,"   the   sub-family   in   "  in^e." 

The  author  of  a  scientific  name  is  the  one  who  first  publishes 


GENERAL  REMARKS  231 

that    name.     One    man    may    describe    the    creature    found    but 
another  may  name  it ;  this  latter  person  is  the  author. 

(2)  The  Rule  of  Priority. 

The  first  name  given  must  be  adopted  by  all  unless  rendered 
invalid.     Hence  Trichina  was  found  to  have  been  applied  to  an 
insect  some  50  years  before  it  was  applied  to  the  new  worm  and 
consequently  was  changed  to  *' Trichinela." 
Different  spelling  can  be  a  different  name. 

(3)  The  Rule  of  Homonyms. 

When  two  distinct  genera  and  species  of  animals  receive  the 
same  name  that  name  applied  first  must  stand. 

(4)  The  Rule  of  Appropriateness . 

No  name  is  allowed  to  be  changed  simply  because  it  is  inappro- 
priate.    An  author  cannot  reject  the  name  he  has  once  given. 

THE  GROUPING  OF  HELMINTHS. 

Helminths  occurring  in  the  human  intestine  belong  to  two  distinct 
groups  of  the  animal  kingdom,  viz.  :  — 
(i)  Platyhelmia,  (2)  Namathelmia. 

Platyhelmia. 

These  are  flat  and  leaf-like.     There  is  no  body  cavity. 

The  mouth  is  at  the  anterior  end,  or  near  to  it,  and  is  on  the  ventral 
surface.     It  is  simple,  forked  or  branched,  but  always  blind. 

There  is  no  hind  gut  or  anus. 

The  muscular  fibres  are  angular,  longitudinal,  and  circular. 
•     The    excretory    system    is   highly    complicated    and    consists    of   a 
branched    set  of   tubules   discharging   at   or    near   the   postero-central 
surface. 

The  sexes  are  not  separate  with  two  exceptions,  the  important  one 
being  the  Bilharzia  haematobium. 

There  are  two  classes  of  Platvhelminths,  Trematoda  and  Cestoda. 

Cestodes  are  really  proliferating  trematodes.  The  latter  consist 
of  a  single  segment,  the  former  of  many.  The  latter  have  an  alimen- 
tary canal,  the  former  none. 

For  classification  see  next  page. 

The  species  will  be  described  according  to  their  pathogenicity  in 
man  under  their  respective  headings. 

Nemathelmia. 

These  are  bilaterally  symmetrically  thread-like  with  a  distinct 
cavity  between  the  body  wall  and  the  gut  in  which  the  genital  organs 
freely  float. 

The  alimentary  canal,  when  present,  is  a  straight  tube  from  mouth 
to  anus,  or  it  may  be  absent. 


232 


DISEASES  DUE  TO  HELMINTHS 


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GENERAL  REMARKS 


233 


Testes  branched. 
=Fasciolinrr. 


Testes  simple. 


T.=Dicrocochinx. 
o7 


T.=Opistlioichina.'. 
T. 


Tape  sliaped. 

.  Heart  shaped. 
Hepnina. 


Gut   branctied.^ 
^t'asciola. 

.  Gut  simple. 
=Fasciolopsis  biiski. 

Special  armature  about  liead. 
=Echinostomincr. 


No  special  armature. 
=Payaj<omiiiiniT. 

T.  &  T.  (Testes  horizontal). 

a 


F.Hiclrcma 


...         ,.  'T.  (Testes  oblique). 

OpUlhorchis  felintis. 
=Testes  lobed. 


•  Opiithcirchh. 
Cloiwrcliis  sinensis. 


.  Ot>islhoichis  novcrca. 
=Testcs  simple. 


Helcrophymr. 


=  Branched  testes. 
- Heterophycs  heierophycs,  genital  pore  at  side  of  ventral  sucker, 
"  Yeokagawa,  genital  pore  and  ventral  sucker  are  fused. 


N.B. 


The  dots  in  the  diagram  show  the  position  of  the  eggs. 

T.  O. 

T.=testis.      O.— Ovary.      T.^itestes  over  ovary.     T.=ovary  over  testes. 


O. 


T. 


FASCiOLiDiB.     Points  of  Differentiation. 


Name 

Size 

Ca;ca 

Testes 

Yolk  Glands 

Cirrus 

Habitat 

Fasciola     ... 

Large, 
leaf  like 

Blanched 

Branched 
posterior 

Full  length 

Present 

Liver 

Echinostoma 

Very  small, 
narrow 

Not  branched, 
long 

Bilobed 

posterior 

Posterior, 
half 

Well 
developed 

Small 
intestines 

Fasciolopsis 

Large 

Not  branched, 
long  and  wavy 

Branched 
posterior 

Full  length 

Very  long 

Small 
intestines 

Opisthorchis 

Long  and 

flat 

Not  branched, 
long 

Lobed 
posterior 

Middle, 
third 

Nil 

Liver 

Clonorchis... 

Long  and 

narrow, 

pigmented 

Not  branched, 
long 

Branched 
posterior 

Middle, 
third 

Nil 

Liver 

Paragonimus 

Broad,  thick 

Not  branched, 
long 

Simple 
posterior 

Whole 
length 

Nil 

Lungs,  &c» 

Ileterophyes 

Small 

Not  branched, 
long 

Simple 

Posterior, 
half 

Nil 

Small 
intestines 

Dicrocoelium 

Medium 

Not  branched, 
short 

Simple 

Middle, 
third 

Present 

Liver 

234  DISEASES  DUE  TO  HELMINTHS 

The  muscular  fibres  are  longitudinal.     There  are  no  cilia. 

The  excretory  system  consists  of  a  simple  bilateral  symmetrical 
system  of  tubules  opening  into  a  single  excretory  pore  on  the  ventral 
surface  of  the  body  in  the  middle  line. 

The  sexes  are  separate. 

The  Nematoda  always  have  an  alimentary  canal.  Nearly  all  those 
found  in  man  are  from  this  class. 

The  Nematomorpha  have  an  alimentary  canal  which  atrophies  in 
the  adult. 

The  Acanthocephala  have  no  alimentary  canal. 

Nemathelmia  pathogenic  to  man  will  be  dealt  with  later. 

THE  PLATYHELMIA  HAVE  THREE  CLASSES. 

Glass  (i)  The  Turbellaria.     Flat  worms,  ciliated^  free-living. 

They  are  not  important  for  man. 
Class  (2)  The  Trematoda.     Flat  worms  with  an  alimentary  canal. 

They  are  parasitic  to  man. 
Class  (3)  The  Castoida.     Flat  worms  without  an  alimentary  canal. 

They  are  parasitic  to  man. 

I TREMATODA  PATHOGENIC  TO  MAN. 

THE  MORPHOLOGY. 

Their  average  length  is  ^  in.,  but  their  extremes  are  i'2^  to  3  in. 

They  are  leaf-like  or  tongue-shaped,  rarely  cylindrical. 

There  are  two  suckers,  one  ventral  and  one  oral,  which  fix  the 
parasites  to  the  lining  of  the  intestine  or  other  organ. 

The  mouth  lies  in  the  oral  sucker. 

The  oesophagus  may  be  long  or  short,  and  often  has  unicellular 
salivary  glands. 

The  intestine  is  branched  or  simple  and  ends  blindly. 

There  is  no  anus. 

The  testes  may  be  branched,  or  simple,  or  lobed. 

The  ovary  may  be  branched,  simple,  or  lobed,  and  is  usually  in 
front  of  the  testes. 

These  characteristics  are  used  to  differentiate  the  species  as  shown 
in  the  preceding  table  of  the  Fasciolidas. 

The  genital  pore  is  usually  near  the  ventral  sucker. 

The  cirrus  pouch  lies  behind  the  genital  pore  and  is  present  in 
some  as  a  muscular  collar  which,  when  it  contracts,  inverts  by  its 
spines  the  canal  they  surround  and  thus  gives  an  erectile  organ  which 
comes  out  of  the  genital  pore. 

The  yolk  glands,  also  used  to  dififerentiate  the  species,  are  arranged 
in  one  of  three  ways,  viz.  :  — 

In  the  middle  third  of  the  body  placed  laterally. 
In  the  posterior  third  of  the  body  placed  laterally. 


GENERAL  REMARKS  235 

In  the  whole  length  of  the  body  placed  laterally. 

They  are  always  small  and  numerous. 

Laurer's  canal  is  on  the  dorsum  and  is  for  the  escape  of  yolk  food 
when  it  is  in  excess,  thus  preventing  the  uterus  being  blocked  with 
volk  (Leiper). 

THE  LIFE-HISTORY. 

This  is  taken  from  a  known  typical  example,  viz.  :  Fasciola 
he  pa  tic  a. 

The  ovum  passes  along  the  ovarian  duct  from  the  ovary  and  in 
this  tube  is  fertilized  and  surrounded  by  yolk  cells. 

The  shell  gland  then  secretes  a  shell  around  the  mass  w'hich  then 
passes  to  the  uterus  and  escapes  in  the  faeces  of  the  parent  worm. 
The  egg  thus  passed  has  a  lid.     (Except  the  Schistomidse.) 

The  ovum  segments  and  grows,  using  up  the  yolk  and  forms  a 
Miracidhim.  This  escapes  in  a  few  weeks  from  the  lid  of  the  egg  into 
the  water.  It  has  two  eye  spots,  anterior  papillae  and  cilia  by  which 
means  it  swims  about.  It  now  grows  and  develops  an  alimentary 
canal.  By  means  of  its  anterior  papillae  it  enters  the  cavity  of  some 
snail,  otherwise  it  dies  in  about  eight  hours.  The  special  organs  are 
now  lost.  The  organism  grows  and  a  sporocyst  is  formed.  Cellular 
differentiation  again  takes  place. 

The  organism  now  has  a  cuticular  lining,  under  which  is  a  muscular 
layer  lined  with  epithelium  internally,  forming  thus  a  cavity  which 
answers  as  an  alimentary  canal.  This  form  is  the  redia.  It  now- 
forces  its  way  out  of  the  cyst  and  wanders  about  the  snail.  It  has  a 
ridge  or  collar  about  its  anterior  end,  and  two  stumpy  protuberances 
posteriorly  to  aid  locomotion. 

Cells  now  bud  off  from  the  inner  side  of  the  body  wall  forming  the 
cercaria.     This  is  something  like  a  young  Fasciola  with  a  tail. 

These  cell  groups  pass  out  from  the  redia  by  the  genital  pore, 
then  leave  the  snail,  swim  about  in  the  water,  become  encysted  on 
grass  and  water  weeds,  and  are  then  devoured  by  sheep,  &c.  In  the 
process  of  ingestion  they  lose  their  cyst,  travel  to  the  bile  ducts,  and 
there  develop  into  mature  flukes  in  about  six  weeks.  It  will  be  noticed 
that  many  flukes  develop  from  one  egg. 

HABITAT. 

They  occur  in  the  liver,  intestines,  lungs  and  urinary  tract  of  man. 

Dogs,  pigs,  cats  and  cattle  are  also  infected. 

In  sheep  they  cause  what  is  commonly  known  as  "  sheep-rot." 

They  may  not  cause  obvious  symptoms  in  man,  but  there  may  be 
irritation  of  any  of  the  above  organs  by  the  eggs  or  the  parasites 
themselves. 

Sometimes  thev  cause  serious  diseases  in  man. 


236 


DISEASES  DUE  TO  HELMINTHS 


TREATMENT. 

In  cases  of  diarrhoea  of  obscure  causation  examine  the  fcTces,  urine 
and  sputum  microscopically. 

Be  careful  about  domesticated  animals ;  they  are  often  a  source  of 
infection. 

All  green  vegetables  should  be  cooked. 

Avoid  the  so-called  edible  snail. 

For  the  specific  treatment  see  the  following  paragraphs. 

THE  CLASSIFICATION  OF  TREMATODES. 

There  are  three  important  families  :  — 
(i)  Fasciolidce,   having  two  testes. 

(2)  Schistosomid^e,  having  one  testis. 

(3)  Paraphistomidie,   having  two  testes. 
For  other  details  see  previous  tables. 


THE  PATHOGENIC  VARIETIES. 

These  will  now  be  dealt  with  serintim. 

Watsonius  watsoni  causes  diarrho'a  and  anaemia. 

It  lives  in  the  small  intestine  and  inflames  the  mucosa. 

It  has  two  pharyngeal  pouches. 

The  oesophagus  divides  into  tAvo  long  intestinal  caeca  arranged 
laterally. 

The  testes  are  lobulated  and  lie  the  one  behind  the  other  in  the 
mid-line. 

The  ovary  lies  behind  the  testes. 

Treat  Avith  eucalyptus  and  chloroform  as  in  Ankylostomiasis. 

Fasciola  hepatica  has  usually  been  found  in  the  liver  of  man,  but 
it  has  been  .found  also  in  the  blood-vessels,  in  the  cranial  cavit>-,  and 
about  the  feet,  forming  there  superficial  abscesses. 

It  is  the  common  liver  fluke  of  herbivorous  animals. 

It  is  very  common  in  Africa,  Burmah,  Egypt  and  other  parts. 

It  is  very  widelv  spread.  It  is  the  cause  of  the  dreaded  "  sheep 
rot." 

The  intestine  divides  into  two  principal  lateral  c^eca,  which  in  turn 
give  olT  man}'  branched  c^eca. 

The  two  testes  are  much  branched  and  lie  behind  each  other  in  the 
mid-line. 

In  front  of  the  ventral  sucker  is  a  cirrus  pouch. 

The  ovary  is  tubular  and  branched.  It  lies  above  and  in  front  of 
the  testes. 

These  worms  are  situated  in  the  bile  ducts  and  cannot  be  dislodged. 


GENERA L  REM A RKS 


237 


238  DISEASES  DUE  TO  HELMINTHS 

Fasciolopsis  huski,  a  large  trematode,  24  to  70  mm.  long,  is  not 
uncommon  in  men  and  pigs. 

It  is  prevalent  in  the  south  of  China  and  other  places. 

The  intestinal  c^eca  which  extend  tO'  the  posterior  are  not 
branched. 

The  cirrus  is  very  long,  being  one  quarter  the  length  of  the  worm. 

The  testes  are  branched  and  are  situated  below  the  ovary. 

The  worms  cause  dysentery  and  diarrhoea. 


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Fasciolopsis  buski.  Lank.  V.s. ,  ventral 
sucker;  C.p.,  cirrus  pouch;  /.,  intestinil 
fork;  S.V.,  viiellaria  :  T.,  testes;  O., 
ovary;  Ms.,  sucker;  Skg.,  shell  ^land  ; 
Ut.,   uterus.      Magnified.      (After  Odhner.) 

Opisthorchis  felineus  has  been  found  in  the  bile  ducts  of  man,, 
causing  inflammation  thereof,  with  atrophy  of  the  liver,  jaundice  and 
ascites. 

The  eggs  containing  a  ciliated  miracidium  are  expelled  in  the  faeces. 

These  parasites  are  more  commonly  found  in  the  gall-bladder  and 
bile-ducts  of  dogs  and  cats. 

The  intestinal  c^ca  are  imbranched. 

The  testes  are  lobulated  and  are  situated  the  one  behind  the  other. 


GENERAL  REMARKS 


239 


Clonorchis  endcmicus  has  been  found  in  the  liver  of  man, 
It  causes  an  enlargement  of  the  liver  with  diarrhoea. 
The  intestinal  CcKca  are  unbranched. 
The  yolk  cells  are  arranged  laterally  in  the  middle  tiiird. 


Ms 


V.s 


_.  I'.sr. 


Dicroccelium  lanceatiim,  Stil.  and  liass. 
15/1.  V.S.,  ventral  sucker;  Cp.,  cirrhus 
pouch;  /.,  intestinal  bifurcations;  V.sc., 
vitelline  sacs;  T.,  testicles;  C,  ovarium; 
His.,  oral  sucker  ;     Ut.,  uterus. 


Clonorchis  sinensis.  C.L., 
Laurer's  canal  ;  Dst.,  viiellaria; 
Ej(.,  excretory  bladder;  ^.,  > 
testes;  K.,  ovary;  R.s.,  recep- 
tacuhim  seminis  ;  Vd.,  terminal 
sectinn  of  vas  deferen-;.  Magni- 
fied 4^  limes.      (After  Looss.) 


Ova  of  Clonorchis   sinensis.     The   knobs  on  the  ends  of  the  eggs 
are  not  shown,     gco/i.     (After  Lcoss,) 


240 


DISEASES  DUE  TO  HELMINTHS 


The  testes  are  much  branched  and  are  situated  behind  the  uterus. 

The  ovary  is  trilobate. 

Paragonimus  zvcstcrmauii  mid  the  schislosonui  are  important  patho- 
logical trematodes,  causing  diseases  in  man  known  as  Paragonimiasis 
and  Schistosomiasis. 

These  will  now^  be  dealt  with  in  more  detail. 


PARAGOXLMIASIS   (Endemic   Ilccmoplysis). 

DEFINITION. 

The  chronic,   local  or  general  infection   of  man  b}'   P.  \\estermanii 
producing  characteristic  cystic  lesions. 


Schistosoma\Iuxmatobium^  Bil.  :  male  carry- 
ing the  female  in  the  canalis  gyncecophorus. 
12/1.     (After  Looss.) 

DISTRIBUTION. 

In  China,  Korea,  Japan,  Formosa,  Philippines,  Sumatra. 

THE  PARASITE. 

This  is  the  P.  westermanii. 


PARAGONIMIASIS  241 

MORPHOLOGY. 

A  greyish  leaf-like  parasite  quarter  of  an  inch  long. 

The  oesophagus  is  short,  the  two  lateral  caeca  are  wavy  but  not 
branched. 

The  testes  are  simple,  one  at  either  side  of  the  mid-line  arranged 
diagonally. 

The  yolk  glands  are  situated  in  the  full  length  laterally. 

There  is  no  cirrus  or  cirrus  pouch. 

Their  life  history  is  not  known. 

They  infect  man,  cats,  dogs  and  pigs. 

The  true  host  is  the  tiger  cat. 

Man  may  be  infected  through  food  or  drink,  and  hence  the  worms 
are  distributed  to  other  parts  through  the  lymphatics.  This  is,  how- 
ever, not  yet  proved. 

The  eggs  are  yellowish  with  a  thick  shell. 

PATHOLOGY. 

The  lesions  have  been  classified  thus  (Musgrave)  :  — 
(i)  The  suppurating  lesion. 

(2)  The  tubercle-like  lesion. 

(3)  The  ulcerating  lesion. 

These  may  occur  in  the  skin,  bronchial  or  intestinal  musosa,  or  in 
the  bile  duct. 

At  first  the  connective  tissue  seems  to  be  infiltrated  with  eggs, 
forming  a  cirrhosis  or  a  round-celled  infiltration  with  eosinophiles. 

An  abscess  may  form  containing  caseous  matter,  or  an  ulcer 
develops. 

If  this  occurs  in  the  liver  cirrhotic  changes  take  place. 

If  it  occurs  in  the  serous  membrane  there  is  an  adhesive  inflam- 
mation with  brown  patches  of  eggs. 

If  it  occurs  in  a  solid  organ,  a  small  focal  cyst  forms  surrounded 
by  fibrous  tissue. 

The  abscess,  cyst  or  ulcer  contains  degenerated  cells,  blood,  eggs 
and  parasites. 

The  fibrous  lesion  spreads  in  a  star-shaped  manner  with  small  cysts 
in  their  centre.  These  reach  the  cutaneous  or  muscular  layer  and  so 
open  intO'  the  skin,  bronchus,  intestine,  or  the  bile  duct,  causing  there 
an  ulcer.  These  ulcers  may  become  secondarily  infected.  The  ulcers 
sometimes  heal  by  scarring. 

Post  mortem,  these  typical  lesions  may  be  found  in  muscle,  lungs, 
serous  membrane,  spleen,  pancreas,  intestine,  bladder,  epididymis, 
prostate,  and  the  choroid  plexus  of  the  brain. 

The  body  is  often  emaciated  and  anaemic. 

16 


242  DISEASES  DUE  TO  HELMINTHS 

Ulcers  sometimes  form  in  the  axilke  or  groin,  from  which  can  be 
found  an  infected  mass  to  the  glands. 

The  lungs  may  show  diffuse  cirrhosis,  bronchiectatic  cavities, 
pneumonia  and  caseous  abscesses. 

SYMPTOMATOLOGY. 

In  a  general  infection  there  are  fever,  enlarged  lymphatic  glands, 
muscular  pains  and  cutaneous  ulcers. 

In  a  thoracic  infection  one  has  cough,  purulent  or  bloody  sputum 
with  eggs,  characteristic  Leyden  crystals.  There  may  be  the  physical 
signs  of  broncho-pneumonia,  a  pleural  effusion,  serous  or  purulent. 
The  sputum  may  be  of  a  red  viscid  gummy  consistency.  The  cough 
is  more  troublesome  in  the  morning  than  at  night. 

In  an  abdominal  infection  there  is  a  dull  general  pain  with 
tenderness.  There  may  be  the  signs  and  symptoms  of  diarrhoea, 
appendicitis,  hepatic  cirrhosis,  &c. 

In  a  cerebral  infection  there  are  the  signs  and  symptoms  of  epilepsy 
which  may  be  Jacksonian. 

DIAGNOSIS. 

This  rests  mainly  upon  finding  the  eggs  in  an  endemic  area. 

TREATMENT. 

This  is  symptomatic.  * 

Remove  the  patient  from  the  endemic  area. 

Pot.  iodides  may  be  tried. 

Give  creosote  for  the  cough  and  to  reduce   the   number  of  eggs. 

SCHISTOSOMIASIS. 
DEFINITION. 

A  chronic  endemic  disease  of  the  urinary  tract  and  rectum,  causing 
hematuria,  cystitis  and  dysenteric  symptoms. 
The  causative  parasites  are  :  — 
(i)  Schistosoma  haematobium. 

(2)  ,,  japonicum. 

(3)  ,,  mansoni. 

In  all  these  trematodes  the  sexes  are  separate. 

(i)  INFECTION  WITH   S.   HAEMATOBIUM. 
DISTRIBUTION. 

Egypt,  South  Africa,  Asia,  India,  Syria,  Mesopotamia,  and  the 
West  Indies,  Madagascar,  Mauritius  and  vSouth  America. 

In  Egypt  the  infection  occurs  in  the  early  winter  months  after  the 
floods.     50  per  cent,  of  the  people  are  infected. 


SCHISTOSOMIASIS 


243 


Calcified  eggs  liave  been  found  in  mummies  of  the  20th  dynasty 
1 250-1000  B.C. 

THE  PARASITE. 

S.  haematobium,  it  is  a  bisexual  trematode. 

MORPHOLOGY. 

The  Male. — This  is  from  12  to  14  mm.  long  by  i  mm.  broad.  It  is 
thin  and  flat,  the  lateral  margins  may  be  turned  inwards  forming  the 
gyn^cophoric  canal  in  which  the  female  lies,  thus  giving  to  the  male 
a  filiform  appearance. 

The  cuticle  is  bossed  with  short  spines  to  enable  it  to  cling  to  the 
walls  of  the  vessels  and  travel  against  the  blood-stream.     There  is  no 


Ovum  of  Schistosoma 
hamalobium,  Bilh.,with 
miracidium,  which  has 
turned  its  anterior  end 
towards  the  posterior 
end  of  the  egg.  275/1. 
{After  Looss. ) 


Ovum  of  Schisiosomum  kcematobium, 
with  terminal  spine.  (Not  found  in 
China.)  The  patient  was  in  the  African 
mounted  police.  (By  William  Pepper, 
Philadelphia.) 


pharynx,  but  the  oesophagus  is  long  with  two  c^eca  which  unite  behind 
the  testes  into  a  median  trunk. 

The  excretory  pore  is  postero-dorsally  situated. 

There  are  four  to  five  testes. 

The  Female. — This  is  20  mm.  long  by  0-25  mm.  thick.  It  is  a 
long,  thin  trematode  with  a  smooth  cuticle  except  about  the  sucker  and 
tail-end,  where  there  are  large  spines. 

The  alimentary  canal  is  as  in  the  male. 

The  uterus  ends  in  a  genital  pore  just  behind  the  ventral  sucker. 

The  eggs  are  large,  o"i8  by  o'o6  mm.,  oval,  yellowish,  with  a  thin 
shell,  slightly  transparent,  no  lid,  and  a  terminal  spine  at  the  posterior 
end. 


244 


DISEASES  DUE  TO  HELMINTHS 


THE  LIFE  HISTORY. 

The  young  immature  male  and  female  are  only  found  in  the  portal 
system  from  whence  they  go  to  the  portal  vein.  Here  they  pair  and 
then  pass  to  the  liver. 

The  male  carries  the  female  down  along  the  portal  and  the  inferior 
mesenteric  veins  to  the  bladder.  Here  oviposition  takes  place  and  the 
eggs  are  deposited  in  the  superficial  capillaries.  From  this  position 
they  gradually  work  their  way  to  the  surface  and  enter  the  bladder  itself. 
Some  of  the  eggs,  however,  become  calcified  in  the  process. 

If  the  eggs  are  taken  from  the  urine  and  examined  they  will  be  seen 


Micrograms  of  sections  of  skin  of  a  newly-born  mouse  which  had  been  immersed  for  half 
an  hour  in  water  containing  large  numbers  of  Bilharzia  cercarise. 


to  contain  a  living  miracidium  which  can  be  liberated  if  the  egg  is 
broken  while  imder  the  microscope. 

The  eggs  must  pass  to  water  at  once  or  the  miracidium   dies. 

It  does  not  live  more  than  thirtv  to  forty  hours  even  when  it  is 
deposited  in  water,  but  must  be  again  taken  up  by  man. 

No  other  host  except  man  has  been  found  to  carry  on  the  infection. 
How  he  becomes  infected  has  not  yet  been  proved. 

The  infection  is  by  ingestion,  also  probably  they  enter  the  skin 
while  people  are  Avorking  in  the  mud  fields  or  bathing  in  the  muddy 
pools  infected  by  the  urine  of  diseased  persons. 

The  eggs  may  work  their  way  to  the  rectal  veins  and  mucous 
membrane,  and  then  be  passed  out  in  the  fseces. 


SCHISTOSOMIASIS 


245 


Others  believe  that  the  life-cycle,  like  that  given  of  a  typical  trema- 
tode  (p.  235),  is  necessary. 

The  African  natives  believe  that  it  gets  along  the  urethra  while  they 
are  bathing,  and  tie  twine  around  the  penis  to  prevent  the  infection. 
Bathing  does  seem  to  account  for  many  infections  and  drinking 
impure  water  for  others.     There  is  no  evidence  for  direct  contagion. 

PATHOLOGY. 

The  irritation  set  up  by  the  eggs  causes  a  round-celled  infiltration. 
The  epithelium  proliferates,  and  flattened  projections  are  formed  which 


Ovum  of  Schistosoinum  luemaiobhim.  For  comparison  witli  Schistosoinu»i  japotnciiin  and 
Schistosomum  tnansoni.  This  parasite  has  not  yet  been  reported  in  China,  and  is  probably 
not  found  there.     (By  William  Pepper,  Philadelphia.) 


feel  sandy  to  the  touch ;  these  may  go  on  to  form  vesicles  and  ulcers  in 
which  eggs  can  be  found.     The  eggs  can  escape  without  ulceration. 

The  bladder  wall  is  much  thickened. 

The  pelvis  of  the  kidneys  and  the  meatus  urinarius  may  also  be 
affected. 

Turner  has  found  the  eggs  in  the  lungs. 

P.M. 

The  bladder  mucosa  is  much  thickened  with  bilharzial  tissue, 
covered  with  adherent  mucus  containing  many  eggs. 

Vesicles  are  most  frequently  found  around  the  trigone,  containing 
a  whitish  fluid  and  eggs.     Papillomata  may  be  formed. 


246 


DISEASES  DUE  TO  HELMINTHS 


These  bleed  readily  and  cause  hcematuria. 

Many  eggs  become  surrounded  by  connective  tissue  and  calcify^ 
forming  sandy  patches,  and  cause  atrophv  of  the  mucosa. 


Ova    of    Schistosoinuiii    japonicuin    in    biliary    ducts,    \    objective. 
(By  Bell  and  Sutton,  Hongkong.) 


Section  of  intestine,  showing  ova  of  Schistosotnum  japoniciim,      x    250. 

(By  J.  Bell,  Hongkong.) 


The  urine  collects  in  the  bladder  depressions,  decomposes,  phos- 
phates form,  and  a  further  phosphatic  incrustation  lines  the  bladder 
wall  more  or  less  in  patches. 


SCHISTOSOMIASIS 


247 


The  ureteric  orifices  may  be  occluded,  causing  retention  of  urine 
and  hypertrophy  of  the  ureters  with  dilatation,  thus  making  ascending 


Case  of  Schistosoniuin  japonicum.  Severe  infection  of  three  years'  duration.  Ova  very 
abundant  in  stools.  After  tapping,  a  large  mass  of  glands  forming  a  tumour  as  big  as  the 
two  fists  together  could  be  felt  in  the  caecal  region.  Liver  dulness  was  diminished.  After 
tapping,  by  pushing  the  hand  well  up  under  the  ribs,  the  liver  surface  could  be  felt  to  be 
bossed.     Spleen  not  enlarged. 

Age  twenty-one.  The  patient  left  the  hospital  a  few  days  after  the  photo  was  taken,  and 
looked  as  if  death  was  imminent.  In  hospital  he  was  tapped  four  times,  but  the  abdomen 
filled  up  to  as  great  a  degree  within  ten  days  of  each  tapping. 

This  illustrates  what  one  might  call  the  final  stage  of  schistosomum  disease,  when  the 
previously  enlarged  liver  shrinks  with  cirrhosis.  The  only  other  photos  I  have  seen  published 
were  those  of  Dr.  Peak's  cases,  but  I  think  they  illustrated  an  earlier  stage  of  the  infection 
(earlier,  or  perhaps  less  severe).     (Notes,  case  and  photos  by  J.  A.  Thomson,  Hankow.) 


septic  infection  easy.     Calculi  may  form  in  the  bladder 
be  interstitial  nephritis. 


There  may 


248  DISEASES  DUE  TO  HELMINTHS 

Bilharzial  tissue  may  form  in  any  part  of  the  urinary  tract. 
It  may  spread  to  the  rectum  and  abdominal  wall  with  sinuses,  and 
may  affect  the  prostate. 

SYMPTOMATOLOGY. 

After  the  Transvaal  War,  many  of  the  soldiers  took  it  with  them  to 
England,  India,  and  to  other  places. 

Incubation  (?)  from  three  to  six  months  (Sandwith). 

The  symptoms  may  be  absent  or  considerable,  according  to  the 
amount  of  the  infection. 

There  are  :  frequency  of  micturition,  burning  pain  about  the 
urethra  and  perin^eum,  straining  after  micturition.  Haematuria  at  the 
end  of  micturition  at  first  (endemic  hcematuria). 

The  urine  centrifuged  shows  the  ova. 

There  may  be  pain  in  the  back,  gluteal  region,  and  down  the  legs. 

The  urine  is  foul-smelling,  decomposes,  is  alkaline,  turbid,  and 
contains  pus,  phosphates,  blood  and  ova. 

Cystitis  sets  in  and  the  other  symptoms  increase. 

There  is  no  rest  dav  or  night. 

A  calculus  may  form  to  add  to  the  misery.     The  prostate  enlarges. 

A  urinary  fistula  may  form  above  the  pubis. 

Pyonephrosis  may  develop,  the  kidneys  enlarge,  and  septicaemia 
set  in.     Prostatic  inflammation  predisposes  to  new  growths. 

Stricture  is  not  uncommon.  In  females  there  is  vaginitis  with 
papillomatous  masses  about  the  vulva.  The  uterus  and  ovaries  have 
been  found  infected. 

Severe  haemorrhage  may  ensue  from  the  large  vessels. 

There  may  be  cirrhosis  of  the  kidneys  with  high  blood-pressure. 

When  the  spinal  cord  is  attacked  the  symptoms  may  imitate  tabes 
dorsalis  or  disserninated  sclerosis. 

TREATMENT. 

Most  cases  cease  to  discharge  eggs  within  five  years  of  leaving  the 
endemic  area. 

There  is  no  specific  drug  for  the  parent  worm. 

Give  male  fern,    u^  v,  t.d.s.  for  a  long  time. 

Give  bladder  washes  of  silver  nitrate  i  in  10,000  at  first,  or  quinine 
4  per  cent.,  or  adrenalin  in  saline. 

Helminthol,  grm.  i,  t.d.s.  may  be  tried. 

Urotropin,  salol,  benzoic  acid,  buchu,  and  hvoscyamus  all  have 
their  advocates.     Good  results  are  claimed  for  emetine. 

Christopherson  claims  that  antimony  tartrate  intravenously  will 
cure.     In  vesicle  infections  inject  along  the  dorsal  vein  of  the  penis. 

Much  water  and  fluids  should  be  given  to  act  mechanically. 


SCHISTOSOMIASIS 


249 


Surgical  treatment  for  calculus  and  fistula  as  rec(uired. 

All  stimulants  and  excesses  must  be  avoided. 

Prohibit  micturition  and  defiecation  inlo  Mnler;  boil  and  filter  all 
drinking  water. 

The  mortality  is  low.  Amongst  affected  Europeans  removed  from 
the  endemic  area  less  than  i  per  cent.  die. 

The  recent  Bilharzia  Mission  to  Egypt,  1915,  consisting  of  Drs. 
Leiper,  R.  P.  Cochin,  J.  G.  Thompson,  has  thrown  much  valuable 
light  upon  this  subject.     A  few  points  are  as  follows  :  — 

The  incubation  of  the  disease  is  probably  one  to  two  months,  and 
is  not  as  long  as  previously  thought. 

The  absence  of  a  pharynx  in  the  cercaria  is  the  one  reliable 
character  by  which  Bilharzia  cercarise  can  be  distinguished  from  other 
distomas. 

Storage  of  water  for  thirty-six  hours  will  destrov  all  cercariae.  If 
this  was  carried  out  with  regard  to  the  Cairo  water  supply  alone,  prob- 
ably the  10,000  children  now  infected  annually  would  be  spared. 

The  extension  of  perennial  irrigation  in  Egvpt  appears  to  have 
encouraged  the  spread  of  the  disease. 

Of  625  men  who  became  infected  in  South  Africa,  359  were  still  on 
the  list  in  191 1,  exclusive  of  those  permanently  pensioned.  The  total 
cost  to  the  State  was  about  ;^'io,ooo  per  annum  (Leiper). 

The  conclusions  arrived  at  by  the  Mission  are  of  interest  as  con- 
trasted with  those  of  I^oos.     They  are  shown  thus  :  — 


Conclusions  based  on  the  Loos 
Hypothesis. 

i,i)  All  transient  collections  of  water, 
such  as  those  resulting  from  occa- 
sional showers  of  rain,  road  water- 
ings and  domestic  waste,  are 
dangerous    if    freshly    contaminated. 

(2)  Large  bodies  of  water,  such  as  the 
Nile  canals,  marshes  and  birkets, 
are  little  liable  to  be  infective. 


(3)  All  water  in  a  given  area  would 
automatically  become  safe  in  30 
hours  if  the  native  infected  popula- 
tion were  removed. 


(4)  Infected  troops  would  be  liable  to 
reinfect  themselves,  to  spread  the 
disease  among  other  troops,  and  to 
convey  the  disease  to  any  part  of  the 
world. 


Conclusions  based  on  the  Results  of 
THE  Present  Inquiry. 

(i)   Transient  collections   of  water  are 
quite  safe  after  recent  contamination. 


(2)  All  permanent  collections  of  water, 
.such    as    the    Nile,    canals,    marshes 

and  birkets,  are  potentially  dan- 
gerous, depending  on  the  presence 
of  the  essential  intermediary  host. 

(3)  The  removal  of  infected  persons 
from  a  given  area  would  have  no 
effect,  at  least  for  some  months,  in 
reducing  the  liability  to  infection,  as 
the  intermediate  hosts  discharge  in- 
fective agents  for  a  prolonged  period. 

(4)  Infected  troops  cannot  reinfect 
themselves  or  spread  the  disease 
directly  to  others.  They  could  only 
convey  the  disease  to  others  in  those 
parts  of  the  world  where  a  local  mol- 
lusc could  efficiently  act  as  carrier. 


250  DISEASES  DUE  TO  HELMINTHS 

(5)  Infection  only  takes  place  through  (5)  Infection  actually  takes  place  both 
the  skin.  by  the  mouth  and  through  the  skin. 

Recently  contaminated  moist  earth  or 
water  is  not  infective. 

(6)  Infection  in  towns  is  due  to  con-  (6)  Infection  in  towns  is  acquired  from 
tact  with  recently  contaminated  moist  unfiltered  water  which  is  still  sup- 
earth  or  water.  plied,  even  in   Cairo,   in  addition  to 

filtered  water,  and  is  delivered  by  a 
separate  system  of  pipes. 
{7)    Eradication    depends    upon    educa-         (7)  Eradication  can  be  effected  without 
tion    and    complete    sanitary    control  the     co-operation     of     infected     in- 

throughout    the    country.      The    sus-  dividuals  by  destroying  the   mollusc 

tained    co-operation    of    the    affected  and  intermediaries, 

individual  is  essential. 

The  practical  conclusions  are  as  follows:  — 

That  unfiltered  water  taken  from  canals,  ditches,  or  birkets  would 
be  rendered  safe  :  — 

(i)  If  kept  beyond  the  survival  period  of  the  cercaria,  i.e.,  forty- 
eight  hours. 

(2)  If  heated  to  50°  C,  a  temperature  at  which  the  cercaria  is  imme- 
diately killed. 

(3)  If  previously  treated  with  those  chemicals  that  are  lethal  to  the 
cercaria. 

The  use  of  tabloids  of  sodium  bisulphate,  16  grains  to  a  pint  of 
water,  giving  a  dilution  of  1-567,  is  recommended. 

The  following  points  should  be  attended  to  :  — 

(i)  Personal  contact  of  any  kind  with  unfiltered  water  is  dangerous. 
The  surface  of  the  water  is  the  most  likely  to  be  infective  as  the  cercariae 
congregate  there.  An  intake  pipe  should  always  be  led,  therefore, 
to  the  centre  of  the  stream,  and  should  draw  the  water  from  near  the 
bottom  and  at  a  place  where  there  is  little  or  no  vegetation. 

(2)  It  is  essential  in  drawing  water  for  storage,  in  order  to  destroy 
the  bilharzia  cercaria,  that  no  infective  mollusc  be  admitted.  This 
can  be  ensured  by  screening  the  intake  pipe  with  gauze  having  about 
sixteen  meshes  to  the  inch.  The  common  mosquito  gauze  or  prosphor- 
bronze  wire  gauze  is  very  serviceable. 

(3)  The  water  in  the  wells  and  "  sakias  "  may  be  regarded  as  much 
safer  than  that  from  other  sources.  Hitherto  molluscs  have  not  been 
found  in  these  wells. 

(4)  Shallow  barrel  sand  filters  are  open  to  suspicion.  It  has  been 
found  experimentally  that  after  fifteen  minutes  cercaria  succeed  in 
passing  in  large  and  increasing  numbers  through  four  inches  of  desert 
sand. 

(5)  Although  the  reproductive  activity  of  bilharzia  in  molluscs  is 
probably  most  intense  during  the  summer  months,  the  occurrence  of 
mature  cercariae  in  infected  molluscs  in  February  shows  that  there  is 
a  certain  liability  to  the  infection  throughout  the  year. 


SCHISTOSOMIASIS 


251 


(2)  IXFECTION  WITH   S.  JAPONICUM. 

DISTRIBUTION. 

This  is  known  in  Japan  as  Katayama  disease  from  a  Japanese  town 
in  which  it  was  common.     The  parasite  is  similar  to  S.  haematobium. 


Schistosoma  japonicutn  : 
from  dog.  Uterine  egg.  X  c. 
800.     (After  Katsurada.) 


Schistosoma  japonic  urn  :    from   dog. 
X   c.  800.     (After  Katsurada). 


Schistosoma  japonicum  :  from  dog. 
Egg  from  faeces.  X  c.  800.  (After 
Katsurada.) 


It  is  found  in  Japan,  China,  and  in  the  Philippines. 

In  China  the  cases  are  only  found  in  the  low-lying  districts. 

THE  PARASITE. 

The  S.  japonicum  is  introduced  by  the  skin  or  mouth  from  polluted 


water. 


252 


DISEASES  DUE  TO  HELMINTHS 


Males  only  have  been  found  to  be  infected,  and  these  were  usually 
farmers  and  boatmen  from  the  ages  of  youth  to  54. 

The  parasite  differs  from  S.  haematobium  in  but  one  or  two  small 
features,  viz.  :  it  is  smaller,  the  male  has  no  tubercles,  the  eggs  are 
oval,  yellowish,  without  an  operculum,  and  no  definite  spine,  but 
Leiper  has  found  a  small  protuberance  in  75  per  cent,  of  those 
examined. 

Some  suppose  that  the  parasites  feed  on  blood,  and  others  that  they 
produce  a  toxin  that  causes  a  progressive  anaemia  in  man. 

The  life-history  is  unknown.  Perhaps  some  fresh-water  mollusc 
or  crustacean  is  necessary. 

PATHOLOGY. 

The  blood-stream  distributes  the  eggs,  which  are  carried  onwards 
until  they  lodge  as  emboli  in  various  organs,  especially  in  the  alimen- 
tary canal  and  liver,  ^\  liere  bilharzial  tissue  is  formed,  causing 
hsemorrhagic  enteritis. 

P.M. 

On  opening  the  abdomen  there  are  signs  of  chronic  peritonitis. 


Schistosoma  japoniciim :    liver  showing  eggs  in  the  intra-  and  inter-lobular   connective 

tissue.      X    (T.  80.     (After  Katsurada.) 

The  liver  is  small,  cirrhotic,  with  nodular  surface.  Glisson's 
capsule  is  thickened,  and  is  found  to  contain  numerous  ova. 

The  intestine  is  thickened,  mucous  membrane  swollen,  hyperasmic, 
friable,  with  patches  of  ulceration  and  necrosis,  sometimes  papillomata. 


SCHISTOSOMIASIS 


253 


The  recto-vesical  pouch  is  almost  obHteraled. 

The  outer  coats  of  the  intestine  are  very  tough,  almost  cartilaginous. 
The  rectum  may  be  three-quarters  of  an  inch  thick  and  adherent  to  the 


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bladder.  The  mucous  membrane  of  this  organ  is  not  usually  affected 
as  in  the  case  of  S.  haematobium. 

There  may  be  haemorrhagic  infiltration  of  the  dura  mater,  with 
wedge-shaped  sclerosed  areas  of  brain  matter  (Katayama). 

The  eggs  may  be  found  in  the  mesentery,  mesenteric  glands, 
mucous  membrane  of  the  gall-bladder,  pancreas,  pylorus,  lungs  and 
brain. 


254  DISEASES  DUE  TO  HELMINTHS 

The  adult  worms  are  found  in  the  portal  system,  especially  at  the 
bifurcation  of  the  smaller  mesenteric  vessels. 

SYMPTOMATOLOGY. 

These  are  very  irregular. 

They  may  be  nil  or  slight  with  urticarial  rashes  and  eosinophilia. 

There  may  be  cough  with  scanty  expectoration,  diminished  breath 
sounds,  and  crepitant  rales. 

During  the  ensuing  months  these  may  increase  and  be  accompanied 
by  diarrhoea,  with  ova  in  the  fasces,  enlargement  and  tenderness  of  the 
liver,  with  general  abdominal  pains. 

The  hvpogastrium  shrinks  and  the  epigastrium  enlarges. 

There  is  dyspepsia  and  the  passage  of  undigested  food  materials. 

The  liver  may  then  shrink  and  the  spleen  enlarge,  followed  by 
ascites,  anaemia,  emaciation,  eosinophilia,  which  latter  may  reach 
50  per  cent. 

If  the  lungs  are  affected  there  are  signs  of  bronchitis  or  of  broncho- 
pneumonia. 

If  the  brain  is  affected  there  are  signs  of  Jacksonian  epilepsy. 

The  knee-jerks  in  these  cases  are  increased. 

The  urinary  tract  is  usually  normal. 

There  may  be  a  muddv  complexion. 

DIAGNOSIS. 

Look  for  a  chronic  enlargement  of  the  liver  and  spleen  with  ascites, 
chronic  diarrhoea,  and  marked  eosinophilia  from  10  pev  cent,  to  50  per 
cent. 

Look  for  ova  in  the  stools  containing  a  miracidium. 

PROGNOSIS. 

Death  nearly  always  ensues. 

Intercurrent  disease  is  usually  the  immediate  cause. 

TREATMENT. 

This  is  as  for  S.  haematobium. 

(3)  INFECTION  WITH   S.   INIANSONI. 
This  parasite  is  held  to  resemble  that  of  S.  hcTmatobium,  but  some 
helminthologists  \\ill  not  accept  that  it  is  a  distinct  species  at  all. 

THE  THEORY  OF  SAMBON. 

In  1903  Manson  found  eggs  with  a  lateral  spine  which  had  attacked 
the  rectum.     He  suggested  that  it  came  from  a  new  species  of  worm. 


INTESTINAL  SCHISTOSOMIASIS  255 

In  1907  Sambon  formed  a  new  species  of  it  and  called  it  S.  mansoni. 
His  reasons  were  that  :  — 

(i)  Lateral-spined  eggs  are   never  found  in  the  urine  or  bladder, 
but  only  in  the  faeces,  rectum  and  liver. 

(2)  The  egg  is  oval  with  a  lateral  spine;  that  of  S.  haematobium  is 

more  oblong  with  a  terminal  spine;  and  S.  japonicum  is  more 
rounded  with  a  very  small  lateral  spine  in  75  per  cent,  of  those 
examined  (or,  as  some  declare,  with  no  spine  at  all). 

The  average  size  of  the  S.  mansoni  egg  is  150  by  65  fi  with 
a  straight  terminal  spine. 

The  average  size  of  the  S.  haematobium  egg  is  115  by  58  /^ 
with  a  thick  lateral  spine. 

The  average  size  of  the  S.  japonicum  egg  is  82  by  68  /^ 
without  a  spine. 

(3)  The  females  differ  in  the  genital  tract,  and  the  uterus  contains 

lateral-spined  ova. 

(4)  The  geographical  distribution  is  different. 

S.  haematobium  only  is  found  at  the  Cape. 

S.  mansoni  only  is  found  in  the  West  Indies  and  S.  America. 

THE  THEORY  OF  LOOS. 

Loos  disagrees  with  the  above  saying  that  the  lateral-spined  eggs 
are  the  products  of  unfertilized  females.  The  females  not  being 
embraced  by  the  male  cannot  withstand  the  blood-stream  and  become 
carried  into  side  channels,  finding  their  way  into  the  bowel.  These 
unfertilized  females  only  shed  laterally-spined  ova  which  are  passed 
in  the  fasces. 

Again  he  says  that  lateral-spined  ova  are  frequently  found  in  the 
fceces.  He  declares  that  there  are  no  differences  between  the  female 
generative  organs. 

The  straight-spined  ova  have  been  found  in  the  urine  in  the  West 
Indies. 

As  man  is  probably  the  intermediate  host,  there  can  be  no  limit  to 
the  S.  haematobium. 

In  191 1  Looss  modified  his  view,  and  stated  that  the  eggs  develop 
pathogenically. 

There  are  many  supporters  of  Sambon's  theory. 

It  is  agreed  that  lateral-spined  ova  cause  :  — 

INTESTINAL   SCHISTOSOMIASIS. 

DISTRIBUTION. 

It    is    found    in    Egypt,    Central    Africa,    Uganda,    South    Africa, 
Belgian  Congo,  America,  and  the  West  Indies. 


256  DISEASES  DUE  TO  HELMINTHS 

PATHOLOGY. 

The  worms  live  in  the  puilal  vein  and  capillaries  of  the  bowel^ 
where  Uiey  lay  their  eggs.  The  eggs  burst  the  capillary,  enter  the 
mucosa,  cause  cellular  infiltration,  thickening,  mucus-covered  papillo- 
mata  and  ulcers.     A  dense  fibrous  infiltration  of  the  peritoneum  results. 

Large  polypoid  masses  may  protrude  through  the  anus. 

A  fistula  may  be  caused  in  the  subcutaneous  tissue  about  the  sacrum 
and  coccyx. 

The  ova  reach  the  liver  by  the  blood-stream,  and  there  form  a  patch 
of  fibrosis  or  an  abscess. 

Gallstones  may  form  around  the  ova  of  the  bladder. 

The  pancreas,  spleen,  urethra  and  vagina  may  be  infected. 

A  chronic  interstitial  pneumonia  may  be  caused  by  ova  reaching 
the  lungs,  and  from  thence  may  enter  the  heart  and  the  general 
circulation. 

SYMPTOMATOLOGY. 

Sometimes  nil  in  slight  infections. 

There  may  be  symptoms  of  chronic  dysentery,  abdominal  pain, 
blood,  mucus,  and  ova  in  the  stools. 

Prolapse  of  the  rectum  or  of  papillomatous  growth  is  not  un- 
common, which  is  sometimes  mistaken  for  hcemorrhoids. 

There  is  great  agony  from  tenesmus  when  at  stool. 

The  prolapse,  inflamed  and  painful,  is  the  source  of  great  discomfort. 

In  cases  where  there  is  more  fibrosis  there  is  diarrhoea  and  consti- 
pation. 

Tumours  are  sometimes  found  about  the  Ccecum  or  colon,  which  are 
hard,  movable,  and  are  elongated  in  the  long  axis  of  the  bowel. 

These  may  increase  during  the  following  months  or  years. 

Emaciation  and  attacks  of  colic  are  common. 

The  liver  may  be  enlarged  and  cirrhotic,  also  the  spleen. 

The  urine  may  be  normal. 

PROGNOSIS. 

This  is  always  unfavourable  when  the  symptoms  are  marked. 
The  patient  must  be  moved  from  the  endemic  area,  if  improvement 
is  to  be  expected. 

TREATMENT. 

Give  male  fern. 

Treat  on  general  lines  as  for  S.  hjcmalobium. 

Whitehead's  operation  may  be  done  for  the  treatment  of  many 
rectal  polypia. 

Irrigation  of  the  intestine  can  be  tried  with  sodium  hypochlorite, 
lo  in  1,000,  or  of  tannic  acid,  3  in  1,000. 


/ 

I  XT  EST  IN  A  L  SCHISTOSOMIASIS  257 

II CESTODA   PATHOGENIC   TO   MAN    (Human   Tapeworms). 

(Kestos  -=  a  girdle.) 

GENERAL  REMARKS. 

Cestoda  are  Plalyhelmia  which  differ  from  Trematodes  in  that  :  — 
(i)  There    is    no    alimentary    system,     the    food    being    absorbed 
through  the  cuticle. 

(2)  There  is  a  simple  fixative  apparatus  at  the  anterior  extremity 
of  the  body. 

(3)  The  parasites  are  divided  into  segments,  each  segment  being  a 
distinct  hermaphrodite  animal. 

(4)  Thev  are  longer  and  flatter,  varying  from  ^  to  24  inches  long. 
The  adult  inhabits  the   intestine,   and  the  larval  form  usually  in- 
habits some  other  host. 

Every  vital  function  is  subordinate  to  the  development  of  ova. 
They  have  been  known  for  centuries. 

Moses  forbade  the  Israelites  to  eat  pigs  and  similar  animals  because 
parasites  were  then  known  to  exist  in  them. 

Aristotle  recognized  the  proglottides  of  tapeworms. 

MORPHOLOGY. 

Cestodaria  with  only  one  segment  and  not  important.  Cestoda 
having  a  scolex  and  segments. 

We  are  concerned  with  these  latter. 

The  true  cestodes  have  a  tape-like  whitish  segmented  body. 

The  anterior  end  has  a  scolex  attached  to  the  intestinal  wall,  the 
segments  or  proglottides  follow  and  increase  in  size  from  the  head 
downwards.  The  head  attaches  itself  to  the  mucous  membrane  of  the 
intestinal  tract  by  means  of  muscular  suckers.  There  may  also  be  one 
or  more  circular  rows  of  hooks  situated  upon  the  most  anterior  part  of 
the  head  or  rostrum.  Each  segment  contains  male  and  female  sexual 
organs.  The  thick  cuticle  contains  lime  salts  in  abundance.  Among 
the  cellular  elements  are  calcareous  corpuscles,  3-30  /x  in  diameter, 
which  are  characteristic  of  the  cestodes,  having  perhaps  a  protective 
or  skeletal  function. 

There  is  an  outer  layer  of  longitudinal  and  an  inner  of  transverse 
muscle  fibre  which  encloses  the  parenchyma. 

There  is  an  excretory  svstem  of  anastomizing  capillaries  passing 
into  collecting  tubules  w^hich  open  to  the  exterior  on  the  last  proglottis. 

The  nervous  system  consists  of  one  ganglion  and  two  nerve  cords. 

The  male  generative  organs  reach  maturity  first.  The  vas  deferens 
from  the  follicular  testes  enters  the  cirrus  pouch  and  terminates  near 
the  vaginal  orifice  at  the  genital  atrium. 

17 


258  DISEASES  DUE  TO  HELMINTHS 

Two  ovaries  develop,  connected  by  a  common  oviduct  which  joins 
the  spermatic  duct.  This  latter  is  then  joined  in  turn  by  the  common 
duct  of  the  yolk  gland  and  the  ducts  of  the  shell  gland,  then  it  passes 
on  to  the  uterus.  This  latter  is  usually  a  blind  tube  but  it  may  be 
open  by  a  special  aperture. 

^^^hen  the  uterus  is  full  of  eggs  it  fills  up  the  proglottis,  and  the 
male  organs  atrophy  and  disappear.     Hence  :  — 

In  the  first  segments  no  sexual  organs  are  seen. 

In  the  slightly  mature  segments  the  male  organs  are  made  out 

first. 

In  the  more  mature  segments  the  female  organs  develop  as  the 

male  organs  diminsh. 

In  the  fully  mature  segments  the  male  organs  have  disappeared. 

THE  LIFE   HISTORY. 

The  mature  proglottis  can  fertilize  itself  or  another  segment. 

The  spermatozoa  pass  along  the  spermatic  duct,  meet  the  ovum  and 
fertilize  it.  The  ovum  then  receives  its  yolk  and  shell,  and  passing  to 
the  uterus  escapes  by  the  uterine  orifice,  when  there  is  one,  or  when  the 
proglottis  is  destroyed. 

The  egg  is  oval,  yellowish  with  or  without  an  operculum. 

Two  membranes  are  formed,  one  near  the  shell,  the  other  near  the 
embryo.  The  shell  and  the  outer  envelope  are  lost  and  in  the  faeces 
is  seen  the  embryophore  in  its  inner  envelope  with  three  pairs  of  hooks. 
This  is  the  Onchosphere. 

Some  species  are  ciliated.  This  onchosphere  is  then  taken  up  by  a 
new  host  of  a  difTerent  class,  the  envelope  is  then  cast  oflf,  the  hooks 
burrow  their  way  to  suitable  tissues,  after  which  its  hooks  are  lost  and  a 
bladder-like  cyst  is  formed.  In  the  walls  of  this  cyst  develops  a  scolex. 
This  cyst  is  called  the 

CYSTICERCUS. 

From  Onchosphere  to  Cysticercus  requires  two  tOi  six  months. 

This  infected  tissue  is  ingested  by  another  animal,  the  cyst  is 
dissolved  and  the  scolex  develops  in  a  few  weeks  to  an  adult  tape- 
worm, which  can  live  for  about  a  year. 

They  obtain  food  by  osmosis  from  the  intestine. 

CLASSIFICATION  OF  CESTODA. 

Order  (i)  Pseudophyllidea.  The  scolex  may  or  may  not  be  armed 
with  two  groove-like  suckers.  It  has  three  genital 
orifices. 

Order  (2)  Tetraphyllidea.     These  parasites  are  not  found  in  man. 


IXTHSTINAL  SCHISTOSOMIASIS 


259 


Order  (3)  Cyclophyllidea.  The  scolex  has  four  suckers  and  tlie 
anterior  end  in  a  rosteUum  with  or  without  hooks.  The 
segmentation  is  distinct.  There  is  no  uterine  orifice. 
The  eggs  are  without  lids. 

Order  (4)  Diphyllidea.     These  are  very  rarely  parasitic  in  man. 

Order  (5)  Trvpanorhyncea.     Not  parasitic  in  man. 

The  sub-families,  genera  and  species  of  Orders  (i)  and  (3)  found  in 
man  are  given  in  the  following  table. 


Order  and 
family 


S:2 


>>  n. 

a. " 

0.2 

u)   o 

'-a 


o  K 


Stib-family 


Dibothriocephalinx 


Ligulinae    ... 
Dipylidiinee 

IlymenoIepiniriEe 
Davaineince 


Genus  and  sub-geniis 
Dibothriocephalus 
Diplogonoporus 
Sparganutn 


Treniinae 


Braunia  ... 
Dipylidium 

Hymenolepis 
Davainea 

/   Tajnia'  .. 

Echinococcus 


j   Hymenolepis 

Drepanido- 
l£enia(?)  ... 


{  Ta-nia 


Tasniorhynchus 


Species 

li: 

D.  latus 

D.  cordatus 

D.  parvus 

(    4- 

U.  grandis 

I    5. 

D.  braundi 

6. 

7. 

S.  mansoni 

S.  prolifer 

8. 

S.  batteri 

9- 

B.  jassyensis 

10. 

D.  caninum 

fii. 

H.  nana 

"I12. 

H.  diminuta 

13- 

H.  lanceolata 

|I4. 

D.  madagascariensis 

D.  asiatica 

16. 

T.  solium 

/I7. 

T.  saginata 

18. 

T.  atricana 

19. 

T.  hominis 

20. 

T.  philippina 

21. 

T.  confusa 

^22. 

T.  bremneri 

.  23- 

(24. 

E.  granulosus 

E.  multilocularis 

MAN  IS  THE  HOST  FOR  :— 

T.   solium,   saginata,  africana,    hominis,   philippina,    confusca  and 
also  T.  bremneri. 

Dibothriocephalus  parvus  and  Hymenolepis  nana. 

Davainea  madagascariensis  and  asiatica. 

Rarely  Dibothriocephalus  latus  which  is  usually  in  the  dog. 

Rarely  Dibothriocephalus  cordatus  which  is  usually  in  the  seal  and 

walrus. 

Rarelv    Hymenolepis   diminuta   which   is    usually    in    the    rat    and 

mouse. 

Rarelv   Drepanidot^enia  lanceolata  which  is  usually  in  ducks  and 

geese. 

CYSTS  MAY  DEVELOP  IN  MAN  FROM  :— 

T.  solium. 

Echinococcus  granulosus  and  multilocularis. 

Larval  forms  of  Sparganum. 

?  Cysticercus  of  T.  saginata. 


26o 


DISEASES  DUE  TO  HELMINTHS 


THE  FOLLOWING  LIST  OF  TAPEWORMS  FOUND  IN  MAN 

will  be  useful  for  reference. 

Table  of  Tapeworms  found  in  Man.     (After  Daniels). 
Platyhelminths 


Turbellaiia 


Tremaloda 


I 
Cestoda 


Pseud  ophyllidise 
Dibothriocephaloidea 


Cyclophyllidiae 


Dipylidium       Hymenolepis       Davainea 


D.  caninum  H.  nana  D.  mada- 

Dibothrio-  Diplo-        Sparga-  H.  diminuta     gascariensis 

cephalus  gonoporus      num  (?) 

I  I.I. 

D.  latus  D.  grandis    S.  mansoni 


Tcenia 

T.  solium 
T.  saginata 
T.  africana 
T.  confusa 
T.  echino- 
cocius 


Only  the  important  species  found  in  man  will  be  dealt  with. 

DIBOTHRIOCEPHALUS  LATUS. 

This  is  the  only  important  helminth  of  the  first  Order. 
It  occurs  in  man,  dogs,  cats  and  foxes. 
It  is  nine  metres  long  and  has  3,000  to  4,000  segments. 
It  has  two  deep  laterally  placed  suckers. 

The  proglottides  are  very  broad,    10  to  20  mm.,   and  are  broader 
than  long. 


""iri 


Various  chain  of  segments 
of  Dibothriocephalus  latns,  show- 
ing the  central  uterine  rosette. 
(Natural  size.) 


»«■  .*  »T  &  •  •  o  «•. 


^ 


-^n<?       '^5-' 


Transverse  section  of  the 
head  of  Dibothriocephalus 
la  'us.     30/ 1 . 


Fairly  mature  proglottis  of  Dibothriocephalus  latus. 
The  viteliaria  are  at  the  sides;  the  uterus,  filled  with 
eggs,  is  in  the  middle,  aUo  ihe  vagina  (ihe  daik  siripe 
passing  almost  straight  from  the  front  to  the  back),  and  the 
vas  deferens  (almost  hidden  by  the  uterus).  Above  in  the 
centre  is  the  cirrus  sac,  and  below  the  shell  gland  and  ovary 
are  seen.     15/1.     (From  a  stained  preparation.) 


I 


INTESTINAL  SCHISTOSOMIASIS 


261 


Diagram  of  genitalia  of  a  Cestode.  ^./..  genital  pore:  2  S  ,  male  and  female 
ducts  opening  into  genital  sinus;  c.s.,  cirrus  sac;  v.d.,  coiled  vas  deferens 
("outer  seminal  vesicle";  va^.,  vagina;  sem.  rec,  seminal  receptacle;  sp.d., 
spermatic  duct;  C.c,  fertiiiEation  canal;  vit.  d.,  vitelline  duct;  sh.  g.,  shell 
gland;  ut.  c,  uterine  canal;  nt.,  uterus;  Ov,,  ovary;  /.,  pumping  organ. 
(Stephens.) 

The  vas  deferens  opens  dorsally  and  the  vaginal  opening  lies 
immediately  behind  it.  The  rosette  uterus  has  four  to  six  convolutions 
and  has  its  separate  opening. 

The  six-hooked  onchosphere  passes  into  the  fish. 

When  the  fish  is  eaten,  adult  worms  are  formed  from  the  oncho- 
sphere, and  the  eggs  are  passed  into  the  faeces  in  twenty-four  days. 

The  Qgg  has  an  operculum,  this  is  the  only  exception.  The  opercu- 
lum is,  of  course,  common  in  trematodes. 

The  onchosphere  has  no  sucker. 

The  parasite  is  found  in  Switzerland,  N.  E.  Europe,  and  Japan. 

The  infection  by  it  produces  a  severe  anaemia  with  fever  and  a 
quick  pulse. 


SPARGANUM. 

This  is  a  term  applied  to  the  larval  stages  of  Dibothriocephalidae, 
which  are  too  premature  for  their  genera  to  be  known. 

S.  prolifer  is  i  to  12  mm.  long  by  2*5  mm.  broad.  The  head  is 
motile  and  can  be  invaginated.  An  apical  depression  serves  as  a 
sucker.  It  can  multiply  by  transverse  fission.  No  genitalia  are  seen. 
The  adult  is  unknown. 

The  parasite  produces  subcutaneous  nodules  in  the  fascia  of  muscles 
and  the  abdominal  cavity  of  man.  There  may  be  an  universal  acne- 
like  itching  eruption. 

A  parasitic  c}'st  usually  contains  one  or  two  worms,  a  watery, 
jelly-like  or  opaque  substance.  The  worms  may  be  encapsulated  in 
the  cysts  and  may  thus  survive  in  man  for  years. 


262 


DISEASES  DUE  TO  HELMINTHS 


DIPYLIDIUM  CANINUM. 

This  parasite  is  found  in  the  dog  and  cat  but  very  rarely  in  man 
and  children.     It  is  15  to  40  m.  long  by  2  mm.  broad. 


Dipylidiiim  caninuiii :  central  portion  of  a  proglottis.  C.p.,  cirrus  sac; 
V.S.,  vitellaria ;  Ex.  v.,  excretojy  vessels;  T.,  testicles  laying  in  the  meshes 
of  the  uterine  reticulum  which  laterally  forms  pouches;  O.,  ovary;  f/.,  reticulu 
of  uterus;  V.,  vagina  and  seminal  receptacle  (below  ovary).  Magnified.  (Aft 
Neumann  and  Railliet.) 


um 
;er 


Dipylidiiim  caniunm  :  development  of  embryo,  i,  solid  hexacanlh  embryo  ;  2,  primitive 
lacuna  {a)  in  the  embryo;  3,  elongation  of  hinder  part,  rudiments  of  sucker  and  rostellum 
appearing;  4,  "body"  and  "tail"  distinct,  (/>)  and  (<r)  excretory  system;  5,  fore-body 
inv'ginates  into  hind-body,  excretory  bladder  has  a  pore;  6,  tail  has  dropped  oft';  scolex 
growing  up  into  secondary  cavity  formed  by  fore-body  ;  the  primitive  cavity  has  been  absorbed 
at  stage  4.     (After  fienham,  Gras^i  and  Rovelli.) 


INTESTINAL  SCHISTOSOMIASIS  263 

The  scolex  has  a  typical  rostelkim  with  three  to  four  rings  of  hooks 
and  four  unarmed  suckers.  The  genitalia  are  double  with  spores  on 
each  side.  Ripe  proglottides  get  into  the  fur  where  eggs  infect  the  dog 
and  cat,  louse  or  flea  in  which  cysticercoids  develop.  The  dog  bites 
the  insect,  gets  the  cysticercoid  on  its  tongue  and  later  licks  man,  thus 
infecting  him.  Cats  may  infect  milk  when  drinking  from  a  household 
vessel  and  children  thus  become  infected. 

HYMENOLEPIS  DIMINUTA. 

This  parasite  is  common  in  rats  and  mice,  rarely  in  children. 
The  cysticercus  is  found  in  the  larva  and  the  imago  of  the  meal- 
moth,  earwig,  and  beetle. 

The  adult  is  20  to  60  cm.  long  by  3*5  mm.  broad. 

It  has  an  unarmed  rostellum  with  four  elliptical  suckers. 

HYMENOLEPIS   NANA. 

This  is  the  dwarf  tapeworm  of  man.  It  is  widely  spread  in  Egypt, 
Europe,  America,  Siam  and  Japan. 

Ten  per  cent,  of  the  children  of  Sicily  are  affected. 

It  is  10  to  15  mm.  long  by  o'6  mm.  broad.  The  smallest  tapeworm 
in  man.  It  has  a  rostellum  Avith  one  ring  of  twenty-four  to  thirty 
hooks,  and  also  has  a  rather  long  neck.  It  has  150  proglottides.  The 
genital  pore  is  marginal.  The  mature  uterus  contains  about  thirty 
eggs.  The  cysticercus  stage  has  not  yet  been  found  ;  perhaps  it  is 
passed  in  some  insect. 

The  symptoms  in  children  may  be  nil  or  slight. 

In  bad  cases  there  is  intestinal  irritation  and  anaemia. 

Infected  children  should  be  isolated  as  infection  spreads  rapidly. 

Male  fern  should  be  given. 

There  may  be  up  to  several  thousand  in  one  individual. 

DAYAINEA   MADAGASCARIENSIS. 

This  is  found  in  children,  but  is  not  very  important. 

It  is  25  to  30  cm.  long  bv  i'^  mm.  broad.  The  scolex  has  four 
suckers  and  a  rostellum  with  ninety  hooks. 

The  proglottides  number  from  500  to  700,  and  are  longer  than 
broad. 

The  genital  pores  are  unilateral,  and  are  situated  near  the  proximal 
corner. 

The  uterus  is  a  many-coiled  tube  which,  when  mature,  uncoils, 
loses  its  wall,  and  the  eggs,  then  free,  become  surrounded  by  cells 
which  form  capsules  for  themselves.  300  to  400  of  these  capsules  may 
exist  in  one  proglottis  in  transversp  rows. 


264 


DISEASES  DUE  TO  HELMINTHS 


TiENIA  SOLIUM. 

The   uterus  consists  of  a  central   stem,    with   seven   to   ten    lateral 
branches  on  either  side,  each  again  branching-. 


Two  fairly  mature  proglottids  of  Tania 
solium,  showing  ovaries  (one  bi-Iobed), 
vitellaria,  central  uterine  stem,  cirrus  and 
vas  deferens  (above),  vagina  (below),  testes 
(scattered),  longitudinal  and  transverse  ex- 
cretory vessels 


Head  of  Tiznia   solium.     4S/1. 


Large  and  small   hooks  of  Tcinia  solium. 
(After   Lfuckait.) 


280/1. 


T<rnia  solium.      21,  egg  with  external  membrane; 
22,  without  (embryophore).      (After  Leuckart.) 


Two  mature  proglottids 
of  Tania  solium  with  fully 
developed  uterus.     2/1. 


This  parasite  is  found  wherever  men  and  pigs  exist. 

It  is  2  to  3  metres  long,  it  has  reached  8  metres,  and  is  about  6  mm. 
broad.  The  scolex  has  a  rostellum,  armed  with  a  double  row  of  hooks 
twenty-two  to  thirty-tw^o  in  number.  There  are  four  hemispherical 
suckers. 


INTESTINA L  SCHISTOSOMIASIS 


26= 


The   proglottides   number   from   800  to   900,   and  are   longer   than 
broad. 


T^r 


A,    Tama  saginata ;    B,  Dipyliditiin  ;    C,   Davaiuea ;    D,   Hynienolepis ;    F,,   Bothriocephaliis 

F,   Diplogonoportis  giandis. 


The  genital  pore  is  lateral  and  irregularly 
alternate. 

Adults  live  solely  in  the  human  intestine 
and  may  exist  there  for  years. 

The  cysticercus  develops  in  the  flesh  of  the 
pig  which,  if  eaten  undercooked,  infects  man. 
This  is  popularly  known  as  "  measly  pork." 

Rarely  is  man  infected  with  the  Cysticercus 
cellulosa^  which,  when  present,  appears  in  the 
brain,  eye,  muscle,  liver  and  lung.  One  or 
more  of  these  organs.  This  infection  is  caused 
by  contaminated  water  or  food. 

The  adult  causes  colicky  pains  and  diarrhoea 
alternating  with  constipation.  There  are, 
emaciation  and  anaemia 
is  infection  by  the  Cysticercus 


The    greater    danger 


T^NIA  SAGINATA. 

Perhaps    this    is    the    largest    tapeworm     in 


A  piece  of  the  muscle 
of  the  ox,  with  three  speci- 
mens of  Cysticercus  bovis. 
Natural  size.  (After  Oster- 
tag.) 


man.     It  is  called  the  unarmed   "beef-worm." 

The  adult  only  occurs  in  man  and  the  cystic  stage   in   cattle.     It   is 

common  in  Africa  and  Asia. 


266 


DISEASES  DUE  TO  HELMINTHS 


The  parasite  is  4  to  10  metres  long  by  4*7  mm.  broad. 
There  are  four  hemispherical  suckers,  often  pigmented, 
sucker  instead  of  a  rostellum. 

The  proglottides  number  about  1,000. 

The  genital  pore  is  lateral  and  placed  irregularly. 


It  has  a 


//'. 


ljS^'i!\Jit>;l»ii"<Bi«i:"i9™"«l*illiilil;Mrti*ulkr'"miiioiiE 


.00 


'v;?rj  ..y  o  Q  ° 


IMIIIMIHiliiHlllHliUcllli 


Vsc. 


S/i' 


Pfoglotlis  of  Tania  saginala,  Goeze,  showing  genitalia.  C,  transverse 
excretory  canal;  N.,  lateral  longitudinal  nerve;  IV.,  longitudinal  excretory 
canal;  T.,  testicles  scattered  throughout  the  proglottis;  Ut.,  opposite  the  central 
uterine  stem  (a  closed  sac)  ;  Ss.,  genital  pore  leading  into  the  genital  sinus  ;  above 
the  cirrus  and  coiled  vas  deferens  (V.d.),  below  the  vagina  {Vag.),  bearing  near 
its  termination  a  dilatation,  the  seminal  receptacle  ;  Vsc,  the  triangular  vilel- 
larium,  and  above  it  (Skg.)  the  shell  gland  ;  leading  from  this  to  the  uterus  is  seen 
the  short  uterine  canal,  on  either  side  of  this  the  twolobed  ovary  [Ov.).      lo/i. 


Egg  of  Diplogonoporiis  graiidis, 
showing  the  morula  surrounded  by 
yolk  cells  and  granules.  440/1. 
(After  Kurimoto.) 


Uterine 


Uterine 


shell  with  filaments  ;  the  oncosphere  with  embryo- 
nal shell  (embryophore)  in  the  centre.  500/ 1. 
(After  Leuckart.) 


Cattle   take   up    the   embryophore    in    contaminated   food    or   water 
which  then  develops  in  their  muscles  as  the  Cysticercus  bovis. 

The  muscles  of  the  tongue  and  of  mastication  are  chiefly  affected. 
Man  is  infected  by  eating  insufficiently  cooked  infected  meat. 
The  cystic  stage  is  very  rare  in  man. 


IXTESriXA L   SCHISTOSOMIA SIS 


267 


The  anaemia  is  more  severe  than  that 
caused  by  T.  sohum. 

The  parasite  is  said  to  be  more  diffi- 
cult to  kill. 

It  is  common  in  Great  Britain. 

It  has  no  rostellum  and  no  booklets. 

The  uterus  has  20  to<  30  lateral  pro- 


a,      oncosphere,      in      its      radially 


cesses    on    either    side,    but    these    do    not  -striated      embryophore       (erroneously 

termed  egg-shell)    of   Taenia  afncaiia. 

again  branch  as  in  T.  solium.  Ikeatly  magnified.  (After  von  Lin- 
Ac  man^'  5,«  -^c^n  immafiirp  mrpsitp';  ''^"^-^  -5,  freed  oncosphere  of  Z)^>j/?- 
AS    man\     as    ^OO    immature    parasites  ^^.^^^^^    caninum.      (After    Grassi    and 

have   been   found   in   one  pound   of  the  Rovelli.)     Both  oncospheres  show  six 

•     -  pines. 

psoas  muscle  of  an  intected  beast. 


ECHINOCOCCUS   GRANULOSUS. 

This  causes  the  cystic  form  of  hydatid 
disease. 

Hydatid  disease  has  been  known  since  the 
days  of  Hippocrates. 

The  cysticercoivi  form  only  occurs  in  man. 


DISTRIBUTION. 

In  Iceland,  Australia,  Europe,  and  Xew 
Zealand;  rarely  in  India  and  South  Africa. 
Egypt  and  the  Philippines. 

The  adult  lives  in  the  intestine  of  dogs, 
jackals,  and  wolves. 

The  cvsticercus  lives  in  man,  sheep,  ox, 
and  pig. 

MORPHOLOGY. 

It  is  about  2 '5  to  6  mm.  long.  It  has  a 
scolex  and  three  segments. 

The  last  proglottis,  when  mature,  equals 
all  the  others  in  size. 

The  scolex  has  four  suckers.  The  rostel- 
lum has  a  double  row  of  twenty-eight  to  tift}- 
hooks.     The  genital  pore  is  alternate. 

The  mature  uterus  has  only  lateral  pro- 
tuberances,  the  eggs  ma\'  form   in   heaps. 

THE  LIFE  CYCLE. 

Man  is  infected  with  the  onchospheres 
when  petting  a  .dog,  or  by  ingesting  con- 
taminated food.     From  the  stomach  the  para- 


7\cnia  echinococciis :  the  cirrus 
sac,  the  vagina,  uterus,  ovary, 
shell  gland  and  vitellariuni,  and 
the  testicles  at  the  sides  are 
recognizihle  in  the  second 
proglottis;  the  posterior  prog- 
lottis shows  the  uterus  partly 
filled  with  eggs,  as  well  as  the 
cirrus  sac  and  the  vagina.     50  i. 


268  DISEASES  DUE  TO  HELMINTHS 

site  bores  its  way  to  the  liver  or  other  organs,  g•ro^\  s  and  forms  a  cyst 
of  three  layers  :  — 

(i)  A  thin  layer  or  endocyst  with  granular,  nulceated  cells. 

(2)  A  thick  outer  layer  or  ectocyst  which  is  laminated  and  opaque. 

(3)  A   connective  tissue  layer  about  the  whole. 

The  inner  layer  of  cells  in  cattle  forms  numerous  hollow  brood 
capsules  called  the  E.  cysticus  sterilis,  which  have  the  endocyst  external 
and  the  ectocyst  internal.  Of  these  brood  capsules,  heads  develop 
called  E.  cysticus  fertilis,  but  these  more  commonly  occur  in  domesti- 
cated animals. 

In  man  daughter-cysts  appear  between  the  strata  of  the  cuticle  into 
which  endocystic  cells  have  found  their  way  and  formed  cysts. 

These  latter  may  grow  and  escape  internally  or  externally.  If 
externally  they  lie  between  the  capsule  and  the  mother-cyst  and  form 
E.  hydatidosus  exogenus,  or  if  internally  they  fall  into  the  mother- 
cyst  and  are  then  known  as  E.  hydatidosus  endogenus.  These 
•daughter-cysts  may  remain  sterile  or  produce  brood  capsules  and 
heads  which  are  then  called  grand-daughter-cysts.  The  wall  of  the 
mother-cyst  may  disappear  and  leave  the  daughter-cysts  free. 

PATHOGENICITY. 

The  cysts  grow  slowly  so  that  the  organs  have  time  to  accommodate 
themselves  somewhat  to  the  changes.  If  the  organ  cannot  expand  the 
symptoms  are  early  and  marked.  If  the  cyst  ruptures  the  fluid  will 
cause  urticarial  symptoms,   rigors,   local  pain,  and  tenderness. 

The  cystic  fluid  is  toxic  and  a  sudden  discharge  of  a  large  cyst 
into  the  abdominal  cavity  may  be  so  toxic  as  to  kill,  acting  upon  the 
heart  like  prussic  acid. 

It  may  rupture  into  the  lung  and  drown  the  patient. 

The  cysts  may  become  fatty,  cheesy,  and  calcified.  They  may 
become  secondarily  infected. 

ECHINOCOCCUS  MULTILOCULARIS. 

This  causes  the  rnuUilocuJar  form  of  hydatid  disease. 

DISTRIBUTION. 

South  Germany,  Switzerland,  Austria,  Russia,  and  Serbia. 
It  is  absent  in  Iceland,  Australia,  and  the  European  districts  where 
the  cystic  form  is  met  with. 

It  occurs  in  animals  and  man. 

MORPHOLOGY. 

The  cysts  are  composed  of  parenchymatous  tissue  internally  and 
■externally.     There  is  no  third  outer  fibrous  coat. 

These  produce  not  only  scolices  but  immature  amoeboid  embryos 


INTESTINAL  SCHISTOSOMIASIS  269 

which  enlarge  the  cvst  and  may  enter  the  blood-slream  and  cause 
metastases. 

The  amoeboid  embryo  is  a  muUiple,  folded,  chitinous  vesicle  which 
forms  a  toxin  detrimental  to  the  host. 

It  is  stated  that  ripe  proglottides  develop  directly  from  the  cyst 
because  it  is  capable  of  producing  living  embryos  with  or  without  a 
capsule. 

The  scolices  are  often  destroyed  by  phagocytes  from  direct  contact 
with  the  host's  tissue. 

Feeding  experiments  have  failed. 

PATHOGENICITY. 

A  primary  tumour  is  formed  in  the  liver,  brain,  spleen,  kidney^ 
adrenals  with  metastases  in  different  organs. 

The  symptoms  varv  according  to  the  organ  afifected. 

There  may  be  anaemia,  emaciation  and  weakness  leading  to  prema 
ture  death. 

THE  TREATMENT  OF  TAPEWORMS. 

(1)  PRELIMINARY. 

When  the  patient  is  not  in  hospital. 
Give  a  brisk  saline  purge. 
No  food  to  be  allowed  for  twelve  hours. 

Then  give  one  to  one  and  a  half  drachms  of  freshh'  prepared  oil. 
of  male  fern  in  gelatin  capsules  or  as  an  emulsion. 

Follow  this  with  one  ounce  of  castor  oil  in  two  hours. 

(2)  THOROUGH. 

When  the  patient  is  treated  in  hospital. 
Absolute  rest  in  bed. 
Light  diet  for  two  days. 

Remove  the  mucus  from  the  intestine  and  about  the  worm  by 
giving  during  this  period  :  — 

Ammonium  chloride,   10  grains  thrice  daily,  &c. 
Small  doses  of  podophyllin  each  morning. 
At  the  end   of  the  second  day  omit  all   food  after  4  p.m.,   and' 
give  at  that  hour  one  ounce  of  Epsom  salts  in  warm  water. 

On  the  third  morning  at  7,  8,  and  9  a.m.  respectively,  give  half  a 
drachm  of  the  freshly  prepared  oil  of  male  fern  each  time. 
At  10  a.m.  give  :  — 

Eucalyptus  oil       ...         ...         ...         ...       ui.  xv 

Chloroform  ...  ...  ...  ...       "i.  xx 

01.  ricini     ...  ...  ...  ...  ...        dr.  v 

No  movement  by  the  patient  is  allowed  during  this  treatment.. 


270  DISEASES  DUE  TO  HELMINTHS 

No  food  to  be  given  until  a  motion  lias  been  passed. 
Fluid  foods  are  to  "be  given  for  the  remainder  of  that  day. 
Preserve  and  examine  all  stools  for  the  scolex. 
The  treatment  for  Echinococcus  is  largely  symptomatic. 

(3)   PROPHYLACTIC. 

Keep  cattle  from  all  faecal  matter. 

Urge  absolute  cleanliness  with  regard  to  food  and  water. 

I'ork  and  beef  meat  should  always  be  well  cooked. 

Ill NEMATODES   PATHOGENIC  TO   MAN. 

Nematodes  belong  to  the  Xemathelminlhs,  Ph\lum  (2)  of  !he 
Metazoa. 

Their  study  is  most  important  as  Filariasis  and  Ankylostomiasis 
are  among  the  diseases  caused  by  these  helminths. 

MORPHOLOGY. 

They  are  white  filiform  worms  covered  with  a  cuticle,  usually 
tapering  at  both  ends  and  enclosing  a  large  undivided  body  cavity. 

There  is  a  mouth  at  the  anterior  end  with  two  to  six  lips  leading 
to  a  thick  muscular  oesophagus  which  may  be  armed  with  teeth. 

The  intestine  is  a  flattened  tube  leading  to  a  short  rectum  or  anus. 

The  excretory  pore  is  in  the  mid-ventral  line  behind  the  mouth,  the 
pore  being  the  outlet  for  two  excretory  tubes  which  unite  to  discharge 
there. 

The  nervous  system  is  a  circum-oesophageal  ring  with  six  anterior 
and  six  posterior  nerve  trunks. 

The  sexes  are  separate. 

The  male  genital  organs,  testes,  vas  deferens,  vesicula  seminales 
and  ductus  ejaculatorius  are  modifications  of  one  tube  which  opens 
close  to  the  anus.     There  are  also  spines  and  papilla. 

The  female  genital  organs,  ovary,  oviduct  and  uterus  are  modifica- 
tions of  two  much-coiled  tubes.  These  unite  forming  the  vagina 
which  opens  in  the  ventral  mid-line  in  front  of  the  anus. 

The  parasites  appear  to  live  upon  intestinal  juices.  Some  enter 
the  villi.     Their  life  histories  differ  and  are  dealt  with   separately. 

THE  PRESERVATION  AND  EXAMINATION  OF  NEMATODES. 

See  end  of  present  section,  p.  321. 

The  most  important  of  these  Nematodes  will  now  be  dealt  with 
seriatim. 

STRONGYLOIDES  STERCORALIS    (Family  Angiostomida) . 

The  adult  is  very  small,  2' 2  mm.  by  34  mm.  long. 
There  are  four  lips  to  the  mouth. 


THE  FILIARIASES  271 

The  oesophagus  is  one  quarter  the  length  of  the  whole  body. 

The  anus  is  just  in  front  of  the  tail  tip.  The  sex  is  doubtful.  It 
is  perhaps  an  hermaphrodite. 

It  is  found  in  the  duodenum  and  jejunum,  deep  in  ihe  mucosa. 

The  parasite  is  widely  distributed. 

The  ova  are  54^^  by  32 ^^i  and  occur  in  the  fccces  during  attacks  of 
diarrhoea.  The  ova  are  normally  deposited  in  the  mucosa,  here  the 
embryos  hatch,  reach  the  lumen  of  the  gut  and  pass  out  in  the  faeces. 
They  grow  into  male  and  female  adults  on  reaching  the  water.  These 
conjugate  and  the  females  then  lay  eggs.  Free  living  embryos  develop 
from  these  which  moult  and  become  filariform  embryos  which  will 
penetrate  the  horny  layer  of  the  skin  and  reach  the  corium  (Mozocchi). 
They  pass,  via  the  lungs,  trachea  and  oesophagus  to  the  small 
intestine  (Fiilleborn).  They  may  also  pass  directly  by  the  blood 
stream.  In  the  small  intestine  they  burrow  into  Lieberkiihn's  follicles 
and  lay  their  eggs. 

These  parasites  cause  an  intestinal  catarrh. 

They  are  the  only  worms  that  pass  embryos  in  fresh  fa?ces. 

GNATHOSTOMA  SPINIGERUM  (Family  Gnathostomidas) . 

The  male,  about  10  mm.  long,  has  two  fleshy  lips  guarding  the 
mouth. 

The  cuticle  in  front  of  the  neck  has  eight  transverse  rows  of  hooks 
pointing  backwards. 

There  are  two  unequal  spicules. 

These  parasites  are  very  rarely  found  in  man.  Only  two  specimens 
are  known. 

They  wander  about  the  connective  tissue  and  form  subcutaneous 
tumours. 

THE  FILARIDiE. 

Diseases  caused  by  Filarice  are  called  Filaruiscs,  manifestations  of 
which  include  F.  lymphangitis,  orchitis,  lymphangiectasis,  abscesses, 
phlebectasis,  varicose  lymphatic  glands,  chylous  extravasations  and 
elephantiasis,   Loasis,    Calabar  Swellings,   and   Volvulosis. 

These  will  be  dealt  with  seriatim. 

THE  FILARIASES. 
HISTORICAL  NOTES. 

Elephantiasis  was  noticed  by  the  ancient  Indian  writers. 
Celsus  first  used  the  term  to  indicate  leprosy,  and  all  writers  since 
have  repeated  the  error. 

Arabian  physicians  described  it  in  the  ninth  and  tenth  centuries. 
Hillary  in  1750  clearly  differentiated  it  from  leprosy. 


2/2  DISEASES  DUE  TO  HELMINTHS 

Chapoton   in    1812  described  Hjematochyluria  in   Mauritius. 

Demarquay  in   1863  found  a  Microfilaria  in  a  hydrocele  at  Paris. 

\\'ucherer  in  1866  found  a  Microfilaria  in  urine,  in  Egypt,  but 
neither  at  the  time  recognized  its  importance. 

Lewis  in  1868  found  the  Microfilaria  in  the  blood  and  lymph  of 
persons  with  elephantiasis  of  the  leg  and  assumed  it  to  be  the  cause. 

Bancroft  in  1876  found  adult  females  in  a  lymphatic  abscess  of 
the  arm,  and  in  a  hydrocele  of  the  cord.  He  afterwards  called  it 
F.  bancrofti. 

Manson  in  1878  found  the  disseminating  mosquito  of  the 
F.  bancrofti  as  well  as  the  periodicity  of  the  Microfilaria,  and  he  also 
showed  that  the  worms  retired  to  the  large  vessels  of  the  lungs  during 
the  day. 

Only  about  ten  adult  filaria  have  been  collected. 

These  parasites  are  non-bursate  nematodes  with  a  simple  mouth 
and  a  limited  number  of  genital  papillae.  The  spicules  are  dissimilar 
in  shape  and  size. 

These  nematodes  always  live  in  the  connective  tissue,  lymphatic 
vessels  and  in  the  blood-stream,  but  never  in  the  intestine. 

When  they  leave  the  human  body  they  pass  at  once  into  some  inter- 
mediate host.  They  do  not  pass  into  water  or  any  other  media.  The 
exception  to  this  is  the  F.  dracunculosis. 

Tlie  skin  of  these  nematodes  mav  be  :  — 

(i)  Smooth,  as  in  F.  bancrofti,  perstans  and  demarquavi. 

(2)  Striated,  as  in  Dirofilaria  mag. 

(3)  Bossed  as  in  Loa  loa. 

(4)  Corrugated  transversely  as  in  F.  volvulus. 

FILARIA  BANCROFTI. 
MORPHOLOGY. 

It  is  a  long,  whitish,  filiform  worm,  with  a  smooth  cuticle  and  a 
globular  head,  with  an  unarmed  lipless  mouth.  Only  one  complete 
specimen  has  ever  been  found  of  the  adult. 

The  tail  of  this  worm  incurves  when  dead.  The  male  measures 
36"6  mm.  long  by  o"i2  mm.  thick.  The  anus,  close  to  the  posterior 
end,  is  guarded  by  two  projecting  lips. 

There  are  six  pairs  of  papillae,  three  pre-anal,  and  three  post-anal. 
There  are  two  curved  retractile  spicules,  o"6  mm.  and  0*2  mm.  long. 

The  female  measures  76  mm.  to  100  mm.  long  by  otS  thick. 

The  vulva  is  close  to  the  anterior  end  and  opens  into  a  single 
vagina,  from  which  two  uterine  tubules  run  almost  the  whole  length 
of  the  body.     These  contain  eggs  and  embryos. 


THE  FILIARIASES 


273 


THE  LIFE-HISTORY. 

The  Adult. — The  males  and  females,  from  three  to  four  inches  long, 
may  be  found  coiled  together  in  the  lymphatic  glands,  or  in  the  lymph- 
atic vessels  of  the  scrotum,  arm,  leg,  epididymis,  testicle  and  hydroceles 


c 
c 

3 


C 
3 


C 
0) 

c 

3 


o  o 

S  := 
« -3 

^^ 

D 
G      . 

■3  o 

i  X 

-a 


■^^ 

O 


of  the  cord;  rarely  in  the  lymphatics  of  the  pelvis  and  abdomen. 

The  males  are  less  numerous  than  the  females. 

The  Ovum. — The  intra-uterine  egg,  50 /^  by  40 /y,  coniaining  a 
coiled-up  embryo,  becomes  elongated  by  the  embrvonic  movements. 
18 


274  DISEASES  DUE  TO  HELMINTHS 

The  embryo  is  set  free  and  is  discharged  from  the  genital  pore.  It  is 
then  free  in  the  lymph  stream  in  which  the  adult  female  happens  to  be. 

The  Embryo. — The  embryo  or  Microfilaria  nocturna  passes  from 
the  lymph  stream  to  the  thoracic  duct,  the  right  heart  and  lungs  to  the 
peripheral  circulation  where  it  is  to  be  found  at  night. 

These  Microfilaria  wriggle  about  in  the  blood-stream,  moving  the 
blood  cells  to  and  fro,  but  without  making  progress.  They  are  about 
300  bv  8  fj,,  with  rounded  anterior  and  tapering  posterior  ends. 
They  are  enclosed  in  a  sheath,  longer  than  itself,  inside  of  which  it 
darts  to  and  fro.  Were  it  not  for  these  sheaths  the  embryo  might  use 
its  anterior  spine  to  escape  through  the  wall  of  the  blood-vessel,  and 
so  avoid  the  mosquito  that  transmits  it. 

A  thick  proboscis  carries  the  spine,  which  can  be  covered  by  a 
retractile  and  protractile  six-lobed  prepuce. 

The  dermo-muscular  transversely  striated  body  encloses  many 
granules  whicli  are  wanting  in  definite  parts  of  the  parasite  thus — 

(i)  In  the  anterior  extremity  of  the  body  (not  the  sheath). 

(2)  In  a  transverse  spot,  21  "5  per  cent,  of  the  whole  length  from  the 
anterior  extremity. 

(3)  In  a  \'^-shaped  spot,  30  per  cent,  of  the  ^hole  length  from  the 
anterior  extremity. 

(4)  In  a  median  line,  the  centre,  63  per  cent,  of  the  whole  lenglh 
from  ithe  anteritM"  extremity. 

(5)  In  an  oval  spot  (tail  spot),  85  per  cent,  of  the  whole  length 
from  the  anterior  extremity. 

(6)  In  a  central  spot,  91 '5  per  cent,  of  the  whole  length  from  the 
anterior  extremity. 

The  significance  of  these  granules  is  not  known. 

Its  Habits  in  Man. — They  are  to  be  found  in  the  peripheral  blood 
ar  night  from  5  j).m.,  increasing  to  midnight,  then  until  8  a.m. 
diminishing.  During  the  day  they  live  in  the  lungs,  large  thoracic 
vessels,   carotid  artery,   heart,   muscle  and  kidney. 

If  man  sleeps  during  the  day  instead  of  at  night  the  periodicity 
will  be  reversed,  but  not  completely,  hence  sleep  may  have  something 
to  do  with  its  periodicity. 

The  common  carrier,  Culex  fatigans,  biles  at  night,  but  the  carrier 
in  Fiji,  Stegomyia  pseudo-scutellaris,  bites  in  the  daytime,  and  Bahr 
says  that  there  the  Microfilaria  are  found  in  the  blood  during  the  day- 
time also,  so  that  the  periodicity  is  controlled  bv  the  habits  of  the 
more  efficient  insect  host.  How  the  Microfilaria  maintain  their 
position  against  the  blood-stream  has  not  been  shown.  One  blood 
film  may  show  as  many  as  500  embryos.  It  has  been  calculated  that 
there  may  be  45,000,000  in  a  fully  grown  man. 


THE  FILIARIASES 


275 


The  number  of  adulls  necessary  to  produce  ihem  is  not  known. 

One  Filaria  can  live  for  several  years  in  the  human  body,  and  a 
Microfilaria  can  live  in  the  blood-stream  for  several  months  (Bancroft). 

Its  Habits  in  the  Mosquito. — The  UKxsquito  sucks  infected  blood; 
the  Microfilaria  passes  to  the  stomach,  where  the  sheath  is  fixed  by 
the  surrounding  haemoglobin  and  also  altered  by  the  gastric  juice. 


Mf.  loa:  in  thick  film,  dried  and 
stained  with  hseniatxylin.  x  1,000.  (After 
Fiilleborn.) 


Mf.  Persians  in  thicl<  film,  dried  and  stained  with 
haematoxylin  ;  4,  unshrunken  ;  5,  shrunken,  x  1,000. 
(After   Fiilleborn.) 


As  a  result  of  these  changes  the  embryo  is  able  to  rupture  the 
sheath  with  its  spine  and  to  escape.  The  stomach  wall  is  then  pierced 
and  the  embryo  passes  to  the  thoracic  muscles,  where  it  grows  con- 
siderably during  sixteen  to  twenty  days.  In  this  position  they  develop 
four  lips,  an  alimentary  canal  and  a  three-lobed  tail.  The  position  is 
now  changed,  and  the  embryo  finds  its  way  to  the  prothorax,  head  and 


2/6 


DISEASES  DUE  TO  HELMINTHS 


labium.  Here  the  parasites  wait,  and  when  an  animal,  usually  man, 
is  bitten,  the  Microfilaria  passes  through  Dutton's  membrane,  and 
enters  the  wound  made  by  the  proboscis  of  the  insect.  When  a  fly  is 
fed  upon  vegetable  matter,  however,  the  MicrofilariiE  will  not  pass 
through.  From  the  wound  the  embryo  passes  into  the  lymphatics, 
where  it  becomes  sexually  mature,  fecundation  is  affected,  and  new 
generations  of  larv^  are  poured  into  the  lymphatic  stream.  These 
then  pass  to  the  thoracic  duct  as  described  above.  The  embryos  are 
often  harmless;  it  is  the  injured  parent  worm  and  the  immature 
products    of   conception    that    are    dangerous.     A    man's    blood    may 


Mf.  demarqiiayi  in  thick  film,  dried  and  stained  with  hsematoxylin.  6,  unshrunken  ; 
7,  shrunken.      X   i,ooo.     (After  Fiilleborn.) 

swarm  with  the  embryos,  and  yet  he  may  show  neither  signs  nor 
symptoms. 

To  demonstrate  the  Microfilaria. — Take  an  ordinary  blood  slide  at 
night,  place  it  at  once  in  weak  fuchsin,  four  minims  to  one  ounce  of 
water,  leave  it  for  one  hour,  and  examine  it  wet  without  a  cover-glass. 
To  partly  decolorize  use  weak  acetic  acid. 

To  fix,  stain  Avith  methylene  blue  for  thirty  seconds  and  examine 
it  wet. 

The  haemoglobin  is  washed  out,  and  the  only  coloured  objects  are 
the  leucocytes  and  the  embryos. 

To  keep  them  alive  for  six  or  seven  d£iys,  ring  a  cover-glass  with 
vaseline  and  place  it  upon  the  fresh  specimen  in  the  ordinary  way. 


THE  FILIARIASES 


277 


The  Diagnosis  of  M 

ICROFILARIA. 

Mf.  BANCROFTi  (noctuma) 

Mf.  Loa  (diurna) 

Mf.  perstans 

Mf.  demarquay 

Length  0317  x  o*oo84mm. 

0-245  ><o'oo75mm.  ... 

o"i95  xo'oo45mm. 

o"2i  X  0-005  'T»rn. 

V  spot  is  '090  mm.  from 

V  spot  is  o*o6o  mm. 

the  head 

from  the  head 

Seen    in    the    peripheral 

Seen     in     the     peri- 

(Adults   in     con- 

(Adults   seen    in 

blood  at  night 

pheral  blood  in  the 

nective     tissue, 

connective 

daytime 

pancreas,      be- 

tissue and  root 

hind      pericar- 

of mesentery)  , 

dium  and  aorta) 

Many  present      

Few  present 

Periodicity  reversible     ... 

Periodicity  not  rever- 
sible 

No  periodicity  ... 

No  periodicity 

Curved  when  dead 

Straight  when  dead 

Sheath  smaller  when  dead 

Sheath  longer    when 
dead 

Nuclear  core  does  not  end 

Nuclear     core     ends 

abruptly 

abruptly 

Nuclei      small,     definite, 

Nuclei    large,    hazy, 

stain  well 

stain  poorly 

Tail  straight  and  pointed 

Tail       curved       and 

Tail  blunted  and 

Tail      sharpely 

pointed 

truncated 

pomted. 
Femalehasbul- 
bous  cutaneous 
expansion      at 
the  tip 

Nuclear  core  does  not  go 

ditto 

Nuclear  core  goes 

Nuclearcoredoes 

to  the  extremities 

to  tip  of  tail 

not  reach  ex- 
tremities 

Has  a  pale  area  about  the 

ditto 

V  spot 

Transversely  striated     ... 

ditto 

Enclosed  in  sheath 

ditto 

No  sheath 

No  sheath 

Adults  found  in  lymphatic 

Adults       found        in 

Adults  in  connec- 

Adults in  connec- 

system 

connective      tissue 
usually 

tive  tissue 

tive  tissue 

In  most  tropical  regions 

In  West  Africa 

In      Africa     and 
British  Guiana 

In  West  Indies 

The  Microfilaria  volvulus  has  no  sheath,  is  sharply  pointed,  and 
does  not  look  unlike  the  Mf.  bancrofti  out  of  its  sheath.  They  are  not 
seen  in  the  blood-stream. 


This  is 
Daniels  :  — 
(i)  The 

(2)  The 
present  in 

(3)  The 

(4)  The 

(5)  The 

(6)  The 
For  the 


The  Diagnosis  of  Microfilaria. 
not  always  easy.      The  points  of  value  are,   according  to 

presence  or  absence  of  a  loose  sheath, 
periodicity — that    is,    the    times    when    the    embryos    arc 
the  blood-stream. 

character  of  the  termination  at  the  narrow  end. 
nuclear  matter  and  how  it  terminates  anteriorly, 
dimensions  of  the  embryo,  dead  and  alive, 
position  assumed  by  the  worm  after  death, 
differential  points  the  reader  is  referred  to  the  table  above. 


2/8  DISEASES  DUE  TO  HELMINTHS 

THE  FILARIASES. 
THE  CHIEF  CAUSATIVE  PARASITE. 

This  is  the  Filaria  bancrofti  as  described  above. 
Its  position  among  the  Nematodes  can  be  seen  at  a  glance  by  refer- 
ing  to  the  table  on  p.  232. 

DISTRIBUTION. 

Asia  is  perhaps  the  endemic  home  of  the  disease.  From  thence  it 
probably  passed  to  Africa,  from  thence  to  America,  from  the  Southern 
United  States  downwards. 

It  is  also  present  in  Australasia. 

It  is  more  common  along  the  sea  coasts  and  the  banks  of  large 
rivers. 

High  air  temperatures  and  considerable  atmospheric  humidity  seem 
to  assist  its  spread. 

Bahr  concludes  that  at  one  time  or  other  every  Fijian  is  the  subject 
of  filariasis. 

50  per  cent,  of  the  Samoans  are  infected. 

S3  per  cent,  of  the  people  of  Cochin  in  India  car^y  it. 

KNOWN  CARRIERS  OF  THE  WORM. 

Culex  fatigans. 

Stegomyia  pseudo-scutellaris. 

Mansonia  uniformis. 

,,  pseudo-titillans. 

Pyretophorus  costal  is. 
Myzomyia  rossii. 
Myzorhynchus  nigerrimus. 

,,  minutus. 

Cellia  albimana. 

The  worm  is  capable  of  undergoing  part  of  its  development  in 
certain  other  mosquitoes. 

PATHOLOGY. 

The  parent  worm  may  not  produce  any  ill-efTects,  but — 

(i)  If  it  obstructs  a  lymph  trunk  the  mechanical  pressure  of  the 
retained  lymph  damages  the  tributar)-  channels,  or 

(2)  If  the  parent  is  injured  abortion  may  ensue,  when  oval  eggs 
instead  of  elongated  embryos  are  passed,  and  these  eggs  being  thicker 
than  the  embryo  are  liable  to  block  up  the  lymph  channel  of  the  skin 
or  lymphatic  gland. 

Heavy  infections  with  parent  worms  have  not  yet  been  described. 

It  must  be  remembered,  however,  that  few  post-mortems  have  been 
recorded.  The  adults  are  difficult  to  find.  When  there  are  varicose 
lymphatics  or  lymphatic  glands  with  clear  lymph,  look  for  the  obstruc- 


THE  FILIARIASES  279 

tion  below  the  jufiction  of  the  lacteals  with  the  receptaculum  chyli,  but 
when  the  fluid  is  milky  the  obstruction  is  beyond  this  point. 

Obstruction  may  be  .caused  by  :  — 

(i)  A  coiled-up  mass  of  worms  behind  a  valve  or  dilated  sinus. 

(2)  A  single  worm  in  a  dilated  lymphatic,  the  draining  gland  being 
probably  blocked  by  aborted  ova. 

(3)  Constant  irritation  caused  by  worms  may  lead  to  the  permanent 
blocking  of  a  main  lymph  channel. 

There  is  often  much  fibrosis  of  the  glands,  when  the  lymphatics  can 
be  seen  collected  in  clusters  between  tissue  strands.  This  condition 
is  accompanied  by  an  excessive  number  of  eosinophile  cells  in  the 
glandular  substance  (Bahr). 

The  clinical  manifestations  are  according  to  the  site  of  the  obstruc- 
tion. This  may  be  anterior  or  posterior  to  the  junction  of  the  lacteals 
with  the  receptaculum  chyli. 

(i)  When  the  obstruction  is  anterior  to  the  junction  of  the  lacteals 
with  the  receptaculum  chyli  there  are  chylous  extravasations.  The 
thoracic  duct  may  be  blocked  which  results  in  the  engorgement  of  the 
lymphatics  of  the  renal,  lumbar  and  the  pelvic  regions  with  dilatation 
of  the  lacteals. 

If  the  engorged  vessels  of  the  urinary  tract  rupture,  chyluria  results. 

If  some  blood  vessels  rupture  also,  as  is  common,  then  one  has 
hsemato-chyluria,  the  milky  opacity  being  due  to  the  large  amount  of 
protein  and  not  to  fat. 

If  the  engorged  vessels  of  the  abdomen  rupture,  one  has  chylous 
ascites. 

If  the  engorged  vessels  of  the  tunica  vaginalis  rupture,  one  has 
chylooele. 

(2)  When  the  obstruction  is  posterior  to  the  junction  of  the  lacteals 
with  the  receptaculum  chyli,  one  finds  ordinary  ascites,  hydrocele  lymph 
scrotum  and  the  varicose  groin  glands. 

The  resistance  of  the  tissues  is  lowered  by  this  condition  and  inflam- 
mation is  readily  set  up  which  may  go  on  to  abscess  and  elephantiasis. 

The  causes  of  Elephantiasis  can  be  grouped  as  follows : — 

(i)  As  described  above. 

(2)  An  injury  to  the  female  worm  may  cause  abortion  and  conse- 
quent obstruction  of  the  lymphatics  by  the  aborted  eggs.  The  normal 
microfilaria  although  250  to  300  fx  long  is  onlv  7  to  8  /x  in  breadth,  v.hile 
the  aborted  eggs  are  50  by  34 /u,  hence  it  can  be  readily  understood  that 
eggs  34  X  in  their  smallest  diameter  would  completely  block  lymphatic 
vessels  along  which  microfilaria  7  to  8  yu.  in  diameter  could  travel. 

Lymph  stasis  causes  inflammation  and  hypertrophy  of  the  connective 
tissue  with  excess  of  lymph  and  hence  the  limb  enlarges  (Manson). 


28o  DISEASES  DUE  TO  HELMINTHS 

(3)  The  condition  may  be  caused  by  a  blockage  of  lymph  channels 
of  the  diseased  area  as  a  result  of  the  frequent  and  prolonged  invasion 
of  the  adult  filaria.  The  microfilariae  may  not  reach  the  blood  but  they 
may  die  in  the  gland.  The  periodic  discharge  of  these  microfi]ari£e  may 
be  a  factor  in  producing  lymphangitis,  orchitis  and  funiculitis,  the 
parent  worm  dying  as  a  result  of  these  inflammatory  attacks  (Bahr). 

In  these  conditions  the  blood  is  usually  normal. 

There  is  often  secondary  anaemia  in  haemato-chyluria  and  diarrhoea. 

Sometimes  there  is  leucocytosis  during  the  febrile  period. 

The  eosinophiles  at  times  may  be  increased  in  blood  examinations. 

P.M. 

The  findings  are  according  to  the  variety  of  the  lesion. 

In  Lymphangitis  the  lymphatic  vessels  are  enlarged  and  inflamed 
with  cyst-like  dilatations  and  the  walls  are  thickened  and  fibrous.  Abs- 
cesses, varying  in  size,  may  contain  dead  worms.  These  dead  worms 
ma\'  become  calcified  ov  the  calcareous  deposit  may  be  gradually 
absorbed  until  onl}-  minute  yellow  spots  remain.  The  worms,  calcified 
or  living,  are  surrounded  by  eosinophilic  cells  in  large  numbers. 

Filarial  abscesses  have  been  found  in  the  gastrocnemius  muscle, 
popliteal  space,  groin,  quadriceps  muscle,  over  the  internal  condyle  of 
the  knee,  in  the  axilUe,  latissimus  dorsi  and  the  serratus  magnus 
muscles,  and  in  the  subcutaneous  tissue. 

In  the  abscesses  are  also  found  Staphylococcus  pyogenes  aureus  and 
Streptococci  pyogenes. 

In  Lymphatic  varicosity  the  vessels  are  much  dilated  with  thickened 
walls.  The  glands  are  dilated,  the  true  gland  tissue  disappears  leaving 
a  fibrous  sac  with  numerous  septa. 

In  Elephantiasis,  the  vessels  are  dilated  and  thickened  in  early  cases. 
There  is  a  round  celled  infiltration  into  the  connective  tissue  of  the  part, 
leading  later  to  the  hvpertrophv  of  the  connective  tissue  of  the  skin  and 
fasciae,  this  latter  including  that  of  muscles,  vessels  and  nerves. 

All  the  tissues  are  sodden  with  lymph. 

The  muscles  show  fatty  degeneration. 

The  bones  are  thickened  or  perhaps  covered  with  osteophytes  or 
more  rarel}-  are  atrophied  and  still  more  rareh-  are  invaded  bv  caseous 
abscesses. 

CLINICAL  VARIETIES. 

(1)  FILARIAL  LYMPHANGITIS.. 

DEFINITION. 

An  inflammation  (jf  the  lymphatic  vessels  in  anv  part  of  the  body 
caused  b\-  Filaria  bancrofti. 


CLINICAL  VARIETIES  281 

SYMPTOMATOLOGY. 

A  shivering  lit,  temperature  101°  to  i04°F.,  vomiting,  headache, 
red  oedema  of  skin  which  is  sometimes  painful,  the  vessels  are  like  a 
red  line  under  the  skin.  The  temperature  falls  in  two  days  accompanied 
by  an  erysipelatous  eruption  which  may  last  several  days  longer.  The 
lymphatic  vessels  return  to  their  normal  condition,  rarely  they  are  left 
as  a  hard  cord  with  the  adult  tilaria  in  the  lumen. 

TREATMENT. 

Rest  in  bed,  mild  purge,  aspirin  for  the  headache,  lead  and  opium 
lotion  locally,   later  ichthyol  and  lanolin  ointment. 
Evacuate  the  abscess  when  necessary. 

(2)  FILARIAL  ORCHITIS  AND  HYDROCELE. 
SYMPTOMATOLOGY. 

Pain  in  the  testes,  fever,  pains  in  the  back,  lower  abdomen  and 
groins. 

There  is  often  bilious  vomiting.  The  testicle  enlarges,  is  tender  and 
painful,  effusion  into  the  tunica  vaginalis  of  lymph  o>r  chyle. 

This  effusion  mav  become  coagulated  and  persist,  or  it  may  form  a 
filarial  h3^drocele  which  may  be  absorbed  or  require  tapping. 

TREATMENT. 

Rest  in  bed,  saline  purges,   lead  and  opium  lotion. 

(3)  FILARIAL  LYMPHANGIECTASIS. 
DEFINITION. 

A  dilatation  of  the  lymphatic  vessels  from  obstruction  due  to  Filaria 
bancrofti. 

SYMPTOMATOLOGY. 

It  can  occur  anywhere  but  it  is  commonly  found  in  the  scrotum, 
spermatic  cord  and  extremities. 

When  it  occurs  in  the  scrotum  there  is  fever,  redness,  swelling, 
pain.  After  the  fever  is  over  the  scrotum  may  remain  swollen  and 
elastic.  It  may  be  smooth  or  rugose,  or  it  may  show  vesicles  which  on 
rupturing  show  lymph  or  clnle  with  filarial  embryos  or  very  rarely 
eggs.  The  discharge  of  l^mph  ma}'  be  so  much  in  twenty-four  hours 
as  to  cause  marked  exhaustion,   the  condition   requiring  operation. 

An  attack  usually  ends  in  diaphoresis. 

When  it  occurs  in  the  spermatic  cord  there  is  pain,  swelling  in  the 
testes,  cord  and  lower  abdomen.  Fever  is  less  frequent  than  in  the 
above  cases.     Later  a  swelling  may  appear  along  the  cord  which  dis- 


282  DISEASES  DUE  TO  HELMINTHS 

appears  when  the  patient  lies  down,  and  reappears  when  he  is  standing. 
The  vessels  are  softer,  less  tortuous  and  more  pouch-like  than  in  true 
varicocele. 

When  it  occurs  in  the  leg  there  is  fever,  enlargement  of  glands,  a 
soft  swelling  in  the  groin  which  disappears  on  the  patient  lying  down 
and  reapjDears  on  standing.  It  does  not  give  any  impulse  on 
coughing. 

TREATMENT. 

Antiseptic  dusting  powder.     Use  a  suspensory  bandage. 
If  the  patient  is  exhausted  from  discharged  lymph  remove  some  of 
the  distended  tissue  and  tie  the  dilated  vessels. 
Elephantiasis  or  chyluria  may  result. 

(4)  FILARIAL  ABSCESSES. 

These  may  occur  in  the  thorax  and  the  retroperitoneal  ilj'jue. 
In  the  latter  case  the  symptoms  may  be  those  of  peritonitis. 
The  dead  body  of  the  parent  worm  is  usually  absorbed  but  if  it  acts 
as  an  irritant  an  abscess  may  arise. 

(6)  FILARIAL  PHLEBECTASIS  (F.  varix). 

This  consists  of  masses  of  enlarged  superficial  veins  which  may 
occur  in  the  axillae,  groin  or  other  regions. 

(6)  VARICOSE  LYMPHATIC  GLANDS. 

These  occur  chiefly  in  the  groin,  the  inguinal  and  femoral  glands, 
less  often  in  the  axillary  and  the  lumbar  (P.M.)  regions. 

The  glands  enlarge  after  each  fever.  They  form  soft  elastic  swell- 
ings, easily  movable,  at  first  covered  with  ncirmal  skin,  but  later  they 
become  fixed  to  the  deep  fascia. 

The  fluid  from  an  exploratory  puncture  shows  at  times  microfilariae, 
and  always  lymph  or  chyle.  The  glands  are  usually  small,  but  they 
may  become  very  large.     They  are  seldom  painful. 

TREATMENT. 

Remove  if  necessary. 

The  condition  is  difficult  to  eradicate  completely. 

Radium  may  be  tried. 

(7)    CHYLOUS   EXTRAVASATIONS. 

Lymph  or  chyle  may  be  extravasated  by  dilated  lymph  or  lacteal 
vessels  into  the — 

(i)  Urinary  passage  causing  chyluria  and  lymphuria. 

(2)  Bowel  passages  causing  chylous  and  lymphatic  diarrhoea. 

(3)  Tunica  vaginalis  causing  chylocele. 


CLINICAL  VARIETIES  283 

(4)  Peritoneum  causing  chylous  ascites. 

These  four  conditions  will   now  be  dealt  with  scrialini. 

(i)  Chyluria  and  Lyviphuria. 

The  dilated  lymphatic  vessels  of  the  urinary  tract  rupture  owing  to 
obstruction  in  or  below  the  thoracic  ducts  and  may  discharge  :  — 

Chyle,  when  the  condition  is  called  chyluria. 

Chyle  plus  blood,  hence  ha^mato-chyluria. 

Lymph,  hence  lymphuria. 

Lymph  plus  blood,   hence  luenialu-l\  inphuria. 

The  only  difference  between  lymph  and  chyle  is  that  the  latter, 
which  is  derived  from  the  lacteals,  contains  65  per  cent,  of  fat,  while 
lymph  contains  about  35  per  cent,  of  fat. 

SYMPTOMATOLOGY. 

The  onset  is  usually  abrupt,  with  \'ague  jjains  in  the  perineum, 
thighs  and  back,  rarely  fever;  more  often  the  passage  of  milky  or 
bloody  urine  is  the  first  sign. 

(A)  The  urine  7nay  pass  out  without  effort. 

The  urine  generally  clears,  then  milky  or  bloody  urine  occurs 
intermittently  for  years,  less  frecjuently  it  is  continuous,  and 
may  last  days,  months,  or  even  years.  Exertion  or  emotion 
may  increase  the  symptoms  or  precipitate  another  attack. 

(B)  The  urine  may  clot  into  a  semi-transparent,  gelatinous,  pinky 

mass  in  the  bladder,  causing  severe  pain  and  strangury. 
There  may  be  considerable  pain  in  passing  small  clots,  efforts 

lasting  some  hours. 
On  standing  the  urine  separates  into  three  layers  :  — 

(i)  A  creamy  upper  layer  of  fat. 

(2)  A  whitish  fluid  with  a  floating  coagulum. 

(3)  A  reddish  sediment. 

This  sediment  contains  fat  and  oil  globules,  fatty  granular 
matter,  a  coagulum  of  fibrin  entangling  microfilaria,  free 
microfilaria,  white  corpuscles,  especially  Ivmph  cells,  red 
cells,  and  calcium  oxalate  crystals. 

The  specific  gravity  is  1015  to  1020. 

The  reaction  is  acid. 

To  estimate  the  fat,  shake  with  ether,  separate,  evaporate  the 
etheF,  and  weigh  the  fat.  This  latter  is  from  o*6  to  2>'3  P^r 
cent. 

Albumin  is  present,  o'6  to  o'9  per  cent,  in  the  resultant  urine. 

If  the  fat  is  not  in  excess,  it  is  lymphuria  or  hsemato-lymphuria 
if  blood  is  present. 

The  amount  of  fat  and  blood  may  vary  in  the  same  patient. 


284  DISEASES  DUE  TO  HELMINTHS 

TREATMENT. 

This  is  symptomatic. 
Rest  in  bed. 
Salol  and  urotropine. 
A  non-irritating  diet.     A'ery  little  fat. 
Gentle  purgation. 

Astringent  injections  and  bladder  washes  are  of  little  use. 
Ouinine  should  be  given. 
The  X-rays  can  be  tried. 

If  clots  persist  in  the  bladder,  ana?sthetize  the  patient,  wash  out  the 
bladder  with  an  aspirator  or  open  and  drain. 

(2)  Chylous  and  Lyuiph  Diarrhoea. 
This  condition  is  rare. 

The  treatment  is  symptomatic. 

(3)  Chylocclc  or  Lymphocclc. 

This  condition  is  often  preceded  by  fever  and  orchitis. 

It  may  develop  gradually,  the  tunica  vaginalis  filling  up  with  an 
opaque  fluid  which  may  contain  microfilaria. 

The  tumours  never  become  very  large,  but  they  may  require 
tapping. 

(4)  Chylous  Ascites. 

This  is  common  in  animals,  but  rare  in  man. 

Two  cases  only  have  been  recorded. 

There  has  been  traumatic  rupture  of  the  receptaculm  chyli  when  it 
has  been  necessary  to  cut  down  and  repair  the  wound. 

In  such  cases  the  intestines  are  matted  together  from  the  exuded 
lymph,  but  there  are  no  indications  for  removing  the  adhesions,  as  they 
are  sterile  and  will  resolve. 

(8)  ELEPHANTIASIS. 
DEFINITION. 

A  chronic  inflammatory  hypertrophy  induced  by  lymph  stasis  in 
fibrous  connective  tissue,  occurring  usually  in  the  skin  and  sub- 
cutaneous tissues  of  the  leg,  scrotum,  vulva,  arm  and  breast. 

CLINICAL  VARIETIES. 

(1)  Elephantiasis  of  the  Leg. 

The  lower  extremities  are  affected  in  97  per  cent,  of  all  cases. 

SYMPTOMATOLOGY. 

There  are  attacks  of  filarial  lymphangitis,  dermatitis  and  cellulitis. 
The  leg  swells  and  partially  resolves  after  each  attack.  The  limb 
permanently  enlarges,  the  natural  folds  of  parts,  such  as  the  ankle- 
joint,  are  exaggerated,  the  dorsum  of  the  foot  becomes  swollen,  while 


CLINICAL  VARIETIES 


285 


in  tlic*  deep  sulci  of  the  folds  epithelial  debris,  sebum  and  sweat 
accumulate,  resulting  in  a  foul  discharge,  followed  sometimes  by 
ulceration. 

The  skin  becomes  dark,    hard  and   thickened.     Roughened  bosses 
or  warty  elevations  are  common  (verrucose  variety). 


Elephantiasis  of  the  legs.     Before  operation. 


There  is  malnutrition  of  the  part,  followed  by  the  shedding  of  hairs 
and  nails,  the  latter  being  rough  and  thick. 

Perspiration  is  diminished.  The  cutaneous  sensibility  is  reduced. 
Ulcers  may  occur  anywhere.  The  thigh  may  become  implicated.  The 
febrile  attacks  may  cease  at  any  time,  leaving  the  leg  enlarged  even  to 
immense  proportions. 

This  condition  may  also  result  without  any  fever. 


286 


DISEASES  DUE  TO  HELMINTHS 


TREATMENT. 

Rest  in  bed.  Methodical  massage  and  bandaging,  the  latter  with 
flannel  or  rubber.     The  pressure  must  be  evenly  distributed. 

Avoid  minor  injuries.     Highly  laced  boots  are  contraindicated. 

Give  fibrolysin  or  thiosinamin  injections,  2  to  4  c.c.  daily,  into 
the  gluteal  region  for  three  to  six  months,  omitting  every  seventh  day. 


Elephantiasis  of  the  legs.     After  operation. 


Elevate  the  limb.     Never  expose  it  to  the  sun. 

To  remove  horny  masses,  employ  a  spirit  lotion  of  resorcin  and 
salicylic  acid. 

After  six  months  remove  long  strips  of  redundant  skin  and  sub- 
cutaneous tissue. 


CLINICAL  VARIETIES 


287 


Poor  results  are  obtained  in  acute,  but  better  in  chronic  cases. 
Some  have  tapped  the  affected  parts  with  Southey's  tubes,  others  have 
cut  out  long  square  masses  and  have  sutured  up  the  cavity,  while  others 
have  inserted  fine  threads  to  form  the  bases  of  new  lymph  channels 
(Lymphangioplasty), 

All   improvements  in  consec^uence  of  these  measures  are  more  or 


Elephantoid  tumour  of  the  buttock. 


less  slight  and  transitory.     Final  and  permanent  results  of  all  surgical 
measures  are  disappointing. 

A  QUERIED  POINT. 

Some  still  ask  :   "  Is  elephantiasis  arabum  caused  by  the  filaria,  as 
these  are  not  usually  present  in  the  blood  or  elsewhere?" 

Sir  Patrick  Manson  answers  :  "  Yes,"  for  the  following  reasons  :  — 


288 


DISEASES  DUE  TO  HELMINTHS 


(i)  The  distribution  of  Filaria  bancrufti  and  elephantiasis  arabum 
correspond. 

(2)  Warix  and  elephantiasis  arabum  occur  in  the  same  districts  and 
individuals. 

(3)  As    varix    is    proved,    elephantiasis    arabum    is    inferred    to    be 

filarial. 


Elephantiasis  of  the  prepuce  (and  legs). 

(4)  Lymph  scrotum  often  terminates  in  elephantiasis  scrotum. 

(5)  When  the  latter  is  removed  there  may  follow  elephantiasis  of 

the  leg". 

(6)  Elephantiasis  and  varix  are  both  diseases  of  the  lymphatics. 

(7)  Both  are  accompanied  by  recurring  lymphangitis. 

The  worm  is  not  found  because  it  may  have  died  after  aborting  the 
ova,  causing  embolism  of  the  lymphatics.  There  then  follow  :  lymph 
stasis,  reduced  resistance  of  tissue,  repeated  mild  sepsis  and  imperfect 


CLINICAL  VARIETIES 


289 


absorption    of    inflammatory    products,    the    natural    result    being    the 
hypertrophy  of  the  Hmb. 


Elephantiasis  scrotum.     Twenty-eight  years  duration. 


Elephantiasis  may  occur  four  to  ten  years  after  microfilariae  have 
been  seen  in  the  blood. 

19 


290 


DISEASES  DUE  TO  HELMINTHS 


There  may  be  sexually  mature  living  filari^  in  the  glands  when 
none  of  the  embryos  have  passed  into  the  blood  (Bahr). 

(2)  Elephantiasis  of  the  Scrotum. 

SYMPTOMATOLOGY. 

A    gradual    enlargement   with   or   without    recurring   erysipelatous 
attacks,  erythema  and  fever.     A  large  triangular  mass  is  formed,  base 


Elephantiasis.     Scrotum. 


downwards.     On  its  anterior  and  superior  aspect  a  canal  is  formed  by 
an  inverted  prepuce  leading  to  the  penis. 

This  organ  is  buried  in  the  tumour.     The  testicles  are  above  and 
behind,  and  are  usually  surrounded  by  hydroceles. 

The  base  of  the  tumour  may  be  ulcerated. 

A  tumour  has  weighed  224  pounds;  10  to  20  pounds  is  common. 

Tumours  weighing  40  to  50  pounds  are  not  infrequent. 

A  localized  groin  tumour  may  weigh  10  to  20  pounds. 

Elephantiasis  of  the  penis  alone  also  occurs. 


CLINICAL  VARIETIES 


291 


TREATMENT. 

Rest,  especially  during-  the  acute  phases. 

Cleanliness.     Avoid  minor  injuries.     Massage. 

Exercise  the  enlarged  glands. 

The  removal  of  the  mass  has  a  mortality  of  5  per  cent.  The  opera- 
tion is  carried  out  as  follows  :  — 

Put  the  patient  to  bed  for  at  least  two  days,  clean  the  skin  carefully, 
suspend  the  mass  in  order  to  drain  it.     Place  a  figure  of  eight  elastic 


Elephantiasis.     Breast.     West  Coast  of  Africa. 


bandage  around  the  pelvis  and  the  neck  of  the  tumour.  Select  good 
skin  for  the  flaps  if  possible.  Turn  the  tumour  upwards  and  incise  for 
flaps  in  front  of  the  anus.  Then  cut  out  the  anterior  flaps  from  the 
pubes  downwards  in  the  mid-line,  ligaturing  the  vessels  as  required. 
Cut  down  the  penile  canal  with  scissors  and  dissect  out  the  testicles 
and  penis.  Pass  a  catheter  as  soon  as  possible;  it  will  serve  as  a  guide 
to  the  urethra  and  penis.  Dissect  out  and  separate  the  mass,  loosen 
the  tourniquet,  and  ligature  any  vessels.  Puncture  or  otherwise  open 
all  hydroceles,  invert  the  sac,  remove  the  redundant  tissue,  and  stitch 


292 


DISEASES  DUE  TO  HELMINTHS 


the  inverted  sac  around  the  testicles.  Suture  skin  flaps  over  testicles 
and  penis  like  the  letter  T  or  Y  with  the  penis  at  the  junction.  Drain 
the  lower  portion  of  the  wound.  Make  skin  flaps  for  the  penis  if 
possible ;  if  not  possible,  then  cover  the  raw  area  with  oil  protective 
and  allow  it  to  granulate.     Dress  aseptically. 

Skin  grafting  should  be  done  early  where  it  is  necessary. 

The  functions  of  the  organs  are  retained  and  restored. 

It  will  facilitate  repair  to  loosen  the  skin  from  the  thighs  with  the 


Elephantiasis.     Penis.     European  some  years  after  leaving    Egypt, 
from  photo,  by   Dr.   Hunt. 

fingers  and  draw  it  inwards  if  there  is  insuf^cient  skin.  Turn  prepuce 
back  to  cover  the  anterior  part  of  the  penis.  The  skin  around  the  penis, 
though  inverted,  is  usually  healthy  and  should  be  retained. 

Complications   are   haemorrhage    and    septicaemia,    also    sometimes 
difficulty  in  copulation,  as  the  scar  tissue  may  bind  the  penis  down. 


(3)  Elephantiasis  of  the  Yulva. 

The  labia  majora  and  clitoris  are  sometimes  affected,  but  it  is  a  rare 
condition. 


CLINICAL  VARIETIES 


293 


These  tumours  may  weigh  from  eight  to  twelve  pounds. 
Remove  the  mass  aseptically. 

(4)  Elephantiasis  of  the  Breast. 

The  condition  is  rare,  but  when  present  the  tumour  may  grow  to 
a  large  size.     One  or  both  breasts  may  be  affected. 
Remove  the  tumour. 

(5)  Elephantiasis  of  the  Arm. 

This  is  a  rare  condition,  but  may  develop  as  in  the  leg,  affecting 
one  or  both  upper  extremities.  The  muscles  are  not  affected.  Treat 
as  for  the  leg. 


Elephantiasis.     Leg.     India. 


(6)  Elephantiasis  of  the  Scalp. 

The  whole  scalp  becomes  very  much  thickened,  and  numerous  folds 
and  deep  furrows  are  formed. 
Treatment  is  symptomatic. 

(7)  Elephantiasis  of  Localized  Areas. 

Pendulous  masses  of  filarial  origin  are  said  to  have  been  found. 
They  may  be  single  or  multiple  and  should  be  removed. 


294 


DISEASES  DUE  TO  HELMINTHS 


Double  conjunctivitis  discharging  chyle  has  been  recorded,  filaria 
also  being  present  (Lewis). 

Acute  synovitis  of  the  knee  associated  with  filaria  is  possible 
(Maitland). 

NOTES  ON  FILARIAL  CARRIERS. 

CULEX  FATIGANS  (Culex  =  gnat). 

This  fly  of  the  sub-family  Culicin^e  is  one  of  the  carriers  of  filaria, 
and  possibly  also  of  the  dengue  parasite. 


Larvse  and  pupte  of  C.  fatigatis,  Wied.,  photographed  from  life, 
about  twice  natural  size. 

MORPHOLOGY. 

The  palpi  are  longer  than  the  proboscis  in  the  male,  and  one-sixth 
the  length  of  the  proboscis  in  the  female. 

The  larva  has  a  breathing  tube.  The  lateral  thoracic  and  abdominal 
hairs  are  not  feathered.  The  head  is  covered  with  narrow  curved  and 
upright  forked  scales  on  the  dorsum.     The  scutellum  is  covered  with 


LOASIS 


295 


narrow  curved  scales,  and  the  wings  with  long,  lateral,  slender  scales 
on  the  veins. 

It  is  of  a  brownish  colour,  with  a  broad  white  and  pale  yellow  band 
across  each  abdominal  segment;  the  ventral  surface  is  pale. 

The  legs  are  brown  except  for  a  small  pale  "  knee  "  spot  at  the 
tip  of  the  femora. 

The  larvcB  may  be  found  in  any  water  near  to  iiuman  dwellings  or 
in  sewage.  They  have  a  long,  slender  breathing  tube  two  and  a  half 
times  the  length  and  twice  the  breadth  of  the  slender  pointed  tracheal 
gills. 

The  antennae  carry  a  fan-like  tuft  of  twenty  long  hairs. 

Habits. — They   breed    in   water-butts,    drains,    and   any    temporary 


Larva  of  Anopheles  iiiaciilipeniiis,  Fabr. 
Enlarged.     (After  Grassi.) 


Larva    of   Culex.      Enlarged. 
(After  Grassi.) 


collection    of    water.      Thev    are    the    commonest    mosquitoes    in    the 
Tropics. 

LOASIS. 

DEFINITION. 

An  inflammatory  condition  of  the  superficial   connective  tissue  or 
conjunctiva  caused  by  the  Loa  loa. 

DISTRIBUTION. 

In  Africa,  chieflv  in  Angola,  Congo,  and  on  the  West  Coast,  where 
it  is  endemic.     It  is  very  common  in  Old  Calabar  and  the  Cameroons. 
Perhaps  it  causes  the  Calabar  swellings. 
It  has  been  imported  to  the  West  Indies. 


296 


DISEASES  DUE  TO  HELMINTHS 


It  seems  to  have  a  restricted  geographical  range. 
Europeans  are  often  infected. 

CAUSATIVE  PARASITE. 

That  a  filaria  has  occurred  in  the  eye  has  been  known  for  four 
centuries.  The  Loa  loa  has  been  found  in  the  ocular  and  palpebral 
conjunctivae,  crossing  the  bridge  of  the  nose,  under  the  skin  over  the 
sterno-mastoid,   scalp,  fingers,   penis,   &c. 


Loa  loa :    the  anterior  end  of  the  male, 
magnified.    (After  R.  Blanchard.) 


Loa  loa  :  anterior  portion  of  the  female 
as  far  as  vulva.     (After  Looss). 


'''^:4'i^-'' '' 


Loa  loam  ^\\.\x.    Natural  size.    (Afler 
Fiilleborn  and  Rodenwaldt.) 


Loa  loa  :  male  on  the  left,  female  on 
the  right.      X  2.     (After  Looss.) 


It  has  rarely  been  found  in  the  anterior  chamber  of  the  eye. 

MORPHOLOGY. 

The  male  is  a  thin,  white,  semi-transparent  worm,  25  to  34  mm. 
long  by  o'4  mm.  thick,  tapering  at  each  extremity  with  a  head  like  a 
truncated  cone,  and  the  tail  incurved  with  a  rounded  tip. 

It  has  transverse  corrugations  of  the  cuticle  with  a  wavy  outline, 
wide  apart  in  the  females  and  close  in  the  males. 


LOASIS 


297 


/ 


/ 


Loa  lea:  on  the  left,  the  hind  end  of  a  male;  on  the  right,  of  a  female.     Note  the  cuticular 
bosses  shown  in  the  figure  of  the  female.      x  285.     (After  Looss.) 


Loa  loa  :  lateral  view  of  tail  of  male  showing  papilkie. 
(After  Lane  and  Leiper.) 


L 


Loa  loa.  a,  ventrolateral  aspect  of 
tail  showing  papillce  and  one  spicule  ; 
b  and  c,  terminations  of  the  two  spicules. 
(After  Leiper.) 


298  DISEASES  DUE  TO  HELMINTHS 

The  anus  is  80  i-i  from  the  tip  of  the  tail.  There  are  three  pairs  of 
pre-anal  and  two  pairs  of  post-anal  papillse. 

The  worm  carries  two  spicules  of  unequal  length ;  the  larger  is 
traversed  by  a  fine  canal  (Penel).  There  are  rounded  bosses  scattered 
over  the  cuticle  averaging  30  yu,  in  height. 

The  mouth  is  terminal,  small,  unarmed,  with  a  powerful  muscular 
cone. 

The  oesophagus  is  short  and  is  not  bulbous. 

The  excretory  pore  is  0*65  mm.  from  the  anterior  end. 

The  worm  has  a  tubular  testis  and  vas  deferens  filled  with  spherical 
spermatozoa,  which  organ  terminates  in  a  vesicula  seminalis  near  to 
the  base  of  the  spicules. 

The  female  is  44  to  63  mm.  long  by  0*4  mm.  thick.  The  vulva  is 
2*5  mm.  from  the  anterior  end. 

LIFE-HISTORY. 

The  unsegmented  egg  is  32  by  17  /x  | 

The  morula  stage  is  40  by  25  /x.  In  uterus. 

The  rolled-up  embryo  is  50  by  25  /x.) 

The  embryo  approaches  the  vulva,  unrolls  and  elongates  itself 
inside  the  egg  membrane  before  it  is  extruded ;  the  embryo  then 
measures  250  by  6  /x  The  embryo  now  escapes  into  the  lymph 
stream  and  blood  current,  where  it  is  known  as  Microfilaria  diurna. 
In  the  circulation  it  enlarges  to  298  by  7*5  /x,  perhaps  by  osmosis. 
The  microfilarias  do  not  completely  fill  their  shealh. 

HABITS. 

They  are  seen  in  the  peripheral  blood  during  the  day,  but  not  at 
night.  They  have  no  relation  to  sleep  as  the  Microfilaria  bancrofti. 
The  curves  are  irregular;  in  the  Mf.  bancrofti  they  are  graceful.  The 
microfilarias  when  found  in  the  peripheral  blood  are  never  in  such 
numbers  as  the  Mf.  bancrofti. 

The  Mf.  diurna  requires  from  three  to  four  years  in  the  human 
body  before  it  reaches  maturity;  they  then  live  for  fifteen  years  or 
more. 

The  immature  forms  are  usually  found  in  children,  but  the  mature 
forms  in  adults. 

The  rate  of  progress  in  the  human  body  is  supposed  to  be  one  inch 
in  two  minutes.  Warmth  such  as  that  from  a  fire  or  the  direct  sun 
will  attract  them  to  the  surface. 

The  worm  becomes  cretified  when  dead. 

CARRIER. 

This  is  the  Chrysops  dimidiata  and  silacea  (Leiper). 

It  is  one  of  the  Tabanidse  with  hind  tibias  armed  with  spurs. 


CALABAR  SWELLINGS  299 

It  has  a  short  proboscis,  the  antennfe  are  longer  than  the  head,  the 
wings  have  a  black  band  running  across  them,  the  eyes  are  golden 
green  during  life,  marked  with  purplish  spots.  The  wings  are  half 
open  when  resting. 

The  female  bites  very  severely,  causing  pain  and  sometimes  inflam- 
mation with  oedema. 

The  eggs  are  deposited  upright  on  leaves  and  plant  stems  near 
water  in  a  single  layer.     They  are  whitish  or  brown  in  colour. 

The  larvce  and  pupce  are  not  unlike  those  of  the  Tabanus. 

The  complete  life-history  is  unknown. 

SYMPTOMATOLOGY. 

These  are  often  nil.  When  the  worm  is  under  the  conjunciiva 
there  are  piercing  pains,  uncertain  vision,  and  swelling  of  the  eyelids. 

There  may  be  some  general  itching. 

They  may  cause  painful  swellings  in  various  parts,  but  these  are 
exceptional.  The  swellings  do  not  suppurate  and  subside  in  a  few 
days. 

The  blood  may  sho^\  a  marked  eosinophilia  up  to  70  per  cent,  of 
the  total  leucocytes. 

TREATMENT. 

This  is  symptomatic. 

CALABAR    SWELLINGS. 
DEFINITION. 

Calabar  swellings  are  smooth,  temporary,  slightly  raised  tumours 
about  the  head,  ankles  and  feet,  probably  caused  by  Loa  loa  and  other 
filarite. 

DISTRIBUTION. 

On  the  West  Coast  of  Africa  only,  especially  about  Southern 
Nigeria  and  the  Cameroons. 

SYMPTOMATOLOGY. 

It  is  not  certain  as  to  how  the  lumps  originate,  but  the  most  likely 
theories  are  :  — 

(i)  That  they  are  the  result  of  the  expulsion  of  microfilariae  from 
the  uterus  of  the  parent  worm.  This  would  explain  their  evanescent 
nature  (Manson). 

(2)  That  they  are  due  to  the  expulsion  of  the  waste  products  of 
the  worms. 

The  swellings  are  often  painless,  the  size  of  half  a  goose's  egg. 

Some  of  them  disappear  quickly,  others  gradually  during  two  to 
three  days. 


300  DISEASES  DUE  TO  HELMINTHS 

There  may  be  nausea,  headache,  slight  pruritus,  with  some  eosino- 
philia  up  to  50  per  cent,  of  the  total  leucocytes  (Stephens). 

The  swellings  do  not  pit  on  pressure,   neither  do  they  suppurate.. 
They  may  develop  singly,  one  coming  as  a  former  one  declines. 

TREATMENT. 

Apply  ichthyol  ointment  or  5  per  cent.  liq.  plumbi  to  the  swellings.. 

VOLVULOSIS. 

The  parasite,  Onchocera  volvulus,  (F'.  volvulus)  was  first  found  in 
tumours  of  the  scalp  and  chest  of  a  negro  on  the  Gold  Coast  by  a 
medical  missionary. 

DISTRIBUTION. 

Sierra  Leone,  Gold  Coast,  Dahomey,  Nigeria,  Cameroons,  and  the 
Congo. 

MORPHOLOGY. 

The  male  F.  volvulus  is  a  whitish,  filiform,  sheathless  embryo  as 
found  in  the  microfilarial  form,  30  mm.  by  0*14  mm.,  with  slightly 
attenuated  ends  and  transversely  striated  cuticle.  The  tail  is  strongly 
incurved.     There  are  nine  pairs  of  papilla^  about  the  anus  (Brumpt). 

It  carries  two  unequal  sj^icules  177  /x   and  82  ft    long. 

They  are  found  in  the  axillae,  popliteal  space,  elbow,  sub-occipital 
region  and  intercostal  spaces.     They  are  common  about  the  chest. 

They  are  not  painful  and  are  easily  enucleated. 

They  do  not  suppurate.  Eggs  and  embryos  may  be  found  in  the 
swellings  when  incised. 

The  female  is  65  mm.  by  0*36  mm.  The  vulva  is  o'76  mm.. from 
the  anterior  end. 

LIFE-HISTORY. 

The  worm  lies  in  a  lymphatic  vessel  which  becomes  inflamed  and 
causes  a  condensation  of  the  adjacent  connective  tissue,  in  which 
become  embedded  both  males  and  females.  In  a  central  lymphatic 
space  the  posterior  end  of  the  male  and  the  anterior  end  of  the  female 
project,  and  in  this  way  copulation  takes  place.  Later  the  embryos 
are  passed  into  this  space.  These  latter  are  from  250  ^  to  300  yit  long 
t>y  5  /"■  fo  6  ^  thick,  with  pointed  tails  and  no  sheath.  The  micro- 
filaria have  not  been  seen  in  the  blood. 

The  adults  may  live  for  years  in  the  human  body. 

Their  complete  history  and  carrier  is  not  known. 

PATHOGENICITY. 

Lymphangitis  and  perilymphangitis  v/ithout  or  with  fever,  leaving 
a  small  tumour. 


DRACONTIASIS  301 

DRACONTIASIS. 
DISTRIBUTION. 

I'ropical  Africa.  In  the  Sudan  it  is  to  be  found  at  Gallabat, 
Gedaref,  Upper  White  Nile,  Kordofan  and  the  Bahr-el-Ghazal 
Province.  India,  Persia,  Turkestan,  Arabia  and  a  few  places  in  South 
.America  where  it  has  been  carried  from  Africa,  such  as  al  British 
Guiana. 

It  is  also  present  in  the  Fiji  Islands. 

It  has  been  seen  in  Europe. 

In  parts  of  the  Deccan  at  certain  seasons  50  per  cent,  are  infected. 

In  parts  of  the  West  Coast  at  certain  seasons  95  per  cent,  are 
infected. 

The  disease  has  been  reported  in  horses,  oxen,  dogs,  &'C. 

THE  PARASITE. 

Dracunculus  medinensis.     (Guinea  worm.) 

Perhaps  this  was  the  fiery  serpent  of  Moses  as  he  knew  the  method 
of  twisting  the  creature  about  a  stick. 

The  host  is  man. 

The  intermediate  host  is  the  Cyclops  quadricornis. 

This  worm  is  the  largest  of  human  lilaria,  its  average  length  being 
about  40  inches  with  extremes  of  12  to  70  inches. 

The  female,  of  which  we  know  the  most,  is  a  long,  white  worm 
with  a  hooked  tail  and  a  large  uterus  which  occupies  nearly  the  whole 
of  the  body  cavity.  The  embryos  when  ready  are  evacuated  from  it 
at  the  anterior  end  near  to  the  mouth.  The  uterus  protrudes  througli 
the  head  parts,  rupturing  them  (Leiper),  and  when  about  one  inch  of 
it  has  passed  the  sac  fills  with  opaque  fluid  and  ruptures.  When  a 
little  water  is  added  the  motionless  embrvonic  forms  uncoil  themselves 
and  swim  about. 

LIFE-HISTORY. 

The  young  are  discharged  into  fresh  water  soon  after  the  parent 
has  broken  the  overlaying  skin  and  before  sepsis  has  set  in.  These 
young  forms  are  taken  into  the  body  cavity  of  a  cyclops  where  in  about 
five  weeks  they  will  develop  into  mature  larvae.  These  are  taken  into 
the  human  stomach  with  drinking  water  or  vegetables,  where  the  o'2 
per  cent,  of  HCl  kills  the  cyclops  and  at  the  same  time  stirs  up  the 
larvce  to  such  activity  that  they  break  through  the  cyclops  at  the  mouth, 
anus  and  genital  opening.  They  then  swim  about  in  the  gastric  fluid 
after  which  they  penetrate  the  gastric  wall  and  so  reach  the  mesenteric 
connective  tissue.     Here  they  copulate  and  the  males  die.     The  preg- 


302 


DISEASES  DUE  TO  HELMINTHS 


Anterior  extremity  of  Guinea 
worm,  showing  dorsal  and  ven- 
tral lips,  one  lateral  and  two 
tubmedian  papillre  and  the 
lateial  line.     (After  Leuckart.) 


Guinea  worm,  Dracun- 
cnhis  medinensis.  (After 
Leuckart.) 


Dracuncuhis  medinensis.  a,  anterior  ex- 
tremity seen  end  on  ;  O,  mouth  ;  P, 
papillse ;  b,  female  reduced  more  than  half; 
c,  larvae  enlarged.     (After  Claus.) 


DRACONTIASIS 


503 


Transverse  section  of  female  Guinea  worm  ;  it.  uterus 
containing  embryos;  ?.  intestinal  canal!;  0.  ovary.  (After 
Leuckart.) 


Cyclops  virescens,  ?  .  8,  Female,  ventral  view,  X  120;  9,  anterior  antennae,  x  240; 
10,  urosome  and  last  thoracic  segment,  x  240;  il,  foot  of  first  pair,  x  320;  12,  15, 
16,  foot  of  second,  third  and  fourth  pairs,  x  240;  14,  foot  of  fifth  pair,  x  440;  13, 
last  thoracic  segment  and  first  segment  of  urosome  of  male,   X  240. 


I 


304  DISEASES  DUE  TO  HELMINTHS 

nant  female  tlien  settles  down  ultimately  in  a  place  where  it  can  deposit 
its  young  in  or  close  to  water.     The  parts  chosen  are  :  — 
(i)  The  ankle  or  lower  leg  in  85  per  cent,  of  cases. 

(2)  The  backs  of  water  carriers  in   India  (doubtful). 

(3)  Rarely  about  the  knee  joints. 

The  life  span  of  a  parent  worm  is  abt)ut  ten  to  twelve  months. 

Therefore,  the  embryos  are  discharged  into  the  water  where  they 
must  be  taken  up  bv  an  intermediate  host,  e.g.,  cyclops  in  which  they 
develop  into  mature  larvae  in  five  weeks  but  in  which  they  can  survive 
for  41  days.  The  larvcC  are  then  swallowed  b\'  man,  or  as  some  assert, 
they  enter  the  skin  of  the  subject  while  he  is  bathing  or  standing  in 
the  water  or  mud.  The  mature  worms  form  in  about  one  year  and 
they  can  persist  for  ten  to  twelve  months  during  A\hich  time  they  dis- 
charge their  embrvos. 

The  life  cycle  is  broken  :  — 

(i)   Bv  death  of  the  embryos  as  a  result  of  sepsis  of  the  wound. 

(2)  Bv  death  of  the  embryos  when  there  is  no  water  near  at  liand. 

(3)  If  nO'  cyclops  is  present  in  the  water  or  if  the  cyclops  dies  or  is 
not  ingested  by  man. 

(4)  If  the  larvce  are  immature  when  ingested  or  fail  to  escape  from 
the  body  cavity  of  the  c\'clops. 

(5)  If  there  are  not  the  two  sexes  in  the  embryos  and  if  the  female 
is  not  impregnated  while  wandering  through  the  connective  tissue. 

PATHOLOGICAL  LESION. 

A  small  bulla  on  the  surface  of  the  skin  about  the  external  malleo- 
lus marks  the  anterior  end  of  the  female  worm.  The  bulla  bursts, 
the  uterus  prolapses,  the  young  are  discharged  and  a  jjortion  of  the 
worm  is  often  extruded,  A\hic]i  the  natives  t\\isl  around  a  stirk  in  an 
attempt  to  extract  it.     This  area  is  very  liable  to  become  septic. 

SYMPTOMATOLOGY. 

An  ulcer  appears  as  above.  Urticarial  eruptions  are  not  un- 
common. 

Rigors  and  fever  may  occur.  Eosinophilia  may  go  up  to  13  per 
cent. 

Synovitis  and  arthritis  are  rare.  The  writer  extracted  one  from  over 
the  internal  tuberosity  of  the  knee  after  synovitis.  The  svnovitis 
trouble  cleared  up  when  the  worm  had  been  removed. 

TREATMENT. 

The  worm  lies  zig-zag  and  even  though  nuicli  may  be  removed  the 
posterior  end  may  have  remained  in  the  same  place,  the  worm  has  only 
been  straightened  in  the  majority  of  attempts  to  remove  it  by  twisting 
it  around  a  stick. 


TRICHOCEPHA  LIASIS 


305 


Douche  the  pari,  where  the  uterus  presents,  wiih  cold  water,  when 
it  will  empty  its  uterus.  The  worm  will  then  be  absorbed,  emerge  or 
in  any  case  it  will  be  easier  to  extract.  The  douching  may  be  required 
several  times  daily  over  two  to  three  ^\eeks. 

If  the  worm  is  visible  or  palpable  under  the  skin  several  incisions 
can  be  made  and  the  worm  removed  in  parts. 

Some  inject  perchloride  solution,  i  in  1,000,  but  they  are  painful 
and  not  very  successful. 

The  native  method  is  often  one  of  straightening  and  not  of 
extracting. 

Treat  the  ulcer  on  ordinary  lines. 

PROPHYLAXIS. 

Carefully  boil  and  filter  all  drinking  water.  A  fine  handkerchief  is 
sufficient. 

Steam  should  be  passed  into  wells  to  kill  the  cyclops  present. 
Avoid  drinking  water  used  for  bathing  purposes. 
Improved  sanitation  will  cause  its  disappearance. 

TRICHOCEPHALIASIS. 

This  is  an  infection  of  the  intestine  by  Trichocephalus  trichiurus 
or  whipworm. 

It  is  cosmopolitan  in  its  distribution. 

THE  PARASITE. 

It  belongs  to  the  famih'  Tricho- 
trachelid^. 

The  male  is  40  to  45  mm.  long 
with  a  spirally  coiled  posterior  end. 

Its  spicule,  2  to  5  mm.  long,  lies 
in  a  retractile  pouch. 

The  female  is  a  little  longer  than 
the  male. 

The  ^gg,  unsegmented  as  it 
appears  in  the  faeces,  is  brown,  oval, 
thick-shelled  with  a  pale  area  at  each 
pole.  Several  months  are  necessary 
before  the  embryo  matures. 

No'  intermediate  host  is  necessary. 

The  embryo  is  ingested  inside  its 
shell  taken  with  either  food  or  drink, 
human     hands     or     flies     acting     as 
carriers.     The  gastric  juice  dissolves  the  shell  and  in  about  four  weeks 
the  embryo  reaches  maturity  in  the  intestine. 

The  worm  can  live  for  years  in  moist  earth. 

20 


Trichurh  trichiura:  on  the  left, 
male ;  on  the  right,  female  with  the 
anterior  extremity  embedded  in  the 
mucous  membrane  of  the  intestine  ; 
below,  egg. 


3o6  DISEASES  DUE  TO  HELMINTHS 

PATHOGENICITY. 

The  worm  is  usually  harmless  although  some  affirm  that  it  causes 
appendicitis  at  limes;  this,  however,  is  very  doubtful. 

Diarrhoea  in  children  living  in  insanitary  conditions  is  more 
common. 

Perhaps  the  head  is  buried  in  the  mucous  membrane  which  makes 
their  ejection  more  difficult  and  thus  disposing  to  bacterial  infection 
at  the  site  of  the  wound.  No  ecchymoses  are  seen  at  the  point  of 
fixation. 

The  eggs  can  infest  utensils  from  dust  long  dried  and  hence  the 
infection  is  not  ah\'avs  due  to  fa?cal  contamination. 

TREATMENT. 

When  there  are  svmptoms  present  treat  as  for  ankylostomiasis. 

TRICHINIASIS. 

This  is  an  infection  of  the  gastro-intestinal  and  muscular  system  by 
the  nematode  Trichinella  spiralis  of  the  family  Trichinellida^. 

The  condition  caused  bv  the  infection  is  of  considerable  importance 
as  shown  bv  the  fact  that  in  Hamburg  alone  loo  inspectors  were 
employed  to  examine  pork,  the  carcases  numbering  from  25,000  to 
30,000  per  month.     This  work  cost  /,'25,ooo  annually. 

DISTRIBUTION. 

It  is  common  in  German v  and  in  some  parts  of  America,  India  and 
China.     It  is  rare  in  England  and  France. 

THE  PARASITE.     LIFE-HISTORY,  &c. 

Two  mammalian  hosts  are  necessary  for  its  development  which 
need  not  be  of  diiTerent  species,  but  no  intermediate  host  is  required. 

The  cysts  are  founci  usual! \'  in  human  or  pig''s  muscle  and  appear 
as  minute  white  specks  which  are  the  encysted  larvae.  Their  long  axis 
lies  in  that  of  the  muscle  fibre.     The\-  measure  400  b\'  230  ^a. 

The  cyst  membrane  is  formed  by  inflamed  connective  tissue. 

The  larvce  may  thus  live  for  years  but  may  become  calcified  and  die. 

The\-  are  chiefly  found  in  the  muscles  of  the  diaphragm,  larynx, 
tongue,  abdominal   and    intercostal    regions. 

These  cysts  are  ingested  alive  witli  the  muscle  fibre  unless  severe 
cooking  has  destroyed  them.  The  gastric  juice  dissolves  the  cyst  wall 
and  the  parasites  emerge  and  pass  to  the  intestine  where  they  become 
sexually  mature,  reaching  i  to  3  mm.  in  length.  Copulation  takes 
place  about  tMo  days  after  the  cvsts  have  been  ingested,  after  which 
the  males  die.  The  females  grow,  penetrate  the  mucous  membrane  of 
the  bowel  and  reach  the  lymph  spaces  and  there  deposit  living  larvae. 

One  adult  female  may  give  rise  to  1,500  larvae. 


TRICHINIASIS 


307 


The  female  lives  from  about  five  to  seven  weeks  doing  this. 

The  larv^  are  carried  by  the  blood  and  lymph  stream  all  over  the 


s     d. 


Trtchinella  spiralis.  ?  ,  mature  female  :  E.  embryos  ;  V,  vulva  :  Ov,  ovar)-.  3  ,  mature 
male  :  T,  testes,  c  newly  born  larva,  d.  larva  in  the  muscles,  c.  encapsuled  larva  in  the 
muscles.     Magnified.     (After  Claus.) 


body.     They   then    leave   the   capillaries,    burrow   their   way    into  the 
tissues  and  in  from  nine  to  ten  days  become  encapsuled  in  the  muscles. 
The  muscle  fibre  infected  degenerates,  becomes  inflamed,  and  a  cyst 
is  formed  from  the  inflammatory  tissue. 


3o8 


DISEASES  DUE  TO  HELMINTHS 


The  cyst  resists  a  temperature  of  8o°C.  or  smoking,  pickling  and 
freezing. 

The    adult    worm    has    an    anterior   part    thin    and    whip-like,    the 


.V' 


r- 


M 


.^^^^         MKi^- 


!     \'i 


v.^S*' 


^  Vaiious    phases    of   the    calcification    of  Tri- 

i  chinella  of  the  muscles,  which  starts  at  the  poles 

/-  1    c  J    T-  ■  u-     1       ■       V  1  "f  i'^^  capsule. 

Calcified    Trichintlia    m    ihe  muscular  ' 

system  of  a  pig  ;    the    capsu'es   are    not 

calcified.     (After  Osterlag.) 

posterior  is  thick  and  carries  the  genitalia,  but  there  is  not  the  abrupt 
transition  as  in  the  Trichocephalus. 

There  are  two  cone-like  appendages.  The  female  vulva  is  placed 
far  forwards. 

This  worm  is  really  a  parasite  of  the  black  rat  (Kpimys  rattus)  and 
the  sewer  rat  (Epimys  norvegicus). 

SYMPTOMATOLOGY. 

There  are  :  irregular  fever  not  unlike  typhoid  ai  times,  some  general 
abdominal  pain  and  tenderness  with  agonizing  pains  as  the  larva? 
burrow  through  the  muscle,  which  pain  lasts  intermittently  for  from 
five  to  seven  weeks.  When  the  muscles  of  respiration,  mastication  or 
deglutition  are  invaded  the  essential  functions  are  rendered  difificult. 

When  the  female  has  finished  depositing  embryos  and  all  have 
become  encysted  the  symptoms  clear  up. 

The  eosinophilia  is  verv  high.  The  larvie  are  not  found  in  the 
blood. 

There  is  often  diarrhoea,  raised  temperature  and  oedematous 
swellings. 

Fatal  peritonitis  may  occur  in  a  heavy  infection. 


TREATMENT. 

Anthelmintics  are  useless. 
The  treatment  is  symptomatic. 


ASCARIASIS 


309 


PROPHYLAXIS. 

All  rats  near  to  pigsties  must  be  destroyed. 

Pigs  must  be  kept  away  from  the  offal  of  slaughter  houses. 

Meat  should  be  cooked  at  a  temperature  of  62°  to  7o°C.  in  all  parts. 

In  some  sausages  the  pork  is  uncooked.  Such  pork  should  be 
examined,  passed  and  marked  by  an  inspector  qualified  for  the  work. 
The  parts  affected  chiefly  are  the  tongue,  laryngeal  muscles,  diaphragm 
and  abdominal  muscles.  To  search  for  the  cysts  press  a  small  portion 
of  the  muscle  fibre  between  two  translucent  glasses  or  plates  when  the 
larvas  are  more  readily  seen. 

The  larvae  are  not  killed  by  freezing,  and  hence  frozen  meat  may 
be  infected. 

ASCARIASIS. 
DEFINITION. 

This  is  an  infection  usually  with  the  Ascaris  lumbricoides  or  round 
worm,  rarely  with  the  Toxascaris  canis  or  Belascaris. 

The  two  latter  are  smaller  and  are  more  commonly  found  in  cats 
and  dogs. 

DISTRIBUTION. 

In  all  tropical  and  sub-tropical  climates. 

The  A.  lumbricoides  is  parasitic  only  in  man.  When  the  eggs  are 
passed  externally  their  development  is  limited  until  re-introduced  into 
man . 

THE  PARASITE.     LIFE-HISTORY. 

The  eggs  are  laid  in  the  small  intestine  and  measure  from  50 /ti  to 
JO  ju,  by  40  ya  10  50^-     They  have  a  thick  yellow  transparent  shell  coated 


/^"P^^^'i 


"%«x::^ 


Ascaris  lumbricoides.     a,  posterior  extremity  of  Ov\xn\oi  Ascaiis  lumbricoides, 

the   male    witii  the  spicules  protruding  from   the  with  shell  and  albuminous  en- 

orifice  of  the  cloaca  {Sp.)  ;  b,  anterior  extremity  velope.     400/1. 

from  the  dorsal  surface,  the  two  lobes  of  the  pulp 
of  the  lip  separated  by  the  "  saddle  "  ;  c,  anterior 
extremity  from  the  ventral  surface  ;  P.,  excretory 
pore.     (From  Claus.) 

irregularly  Avith  albumin  and  stained  a  brownish  yellow  by  fcecal 
material.  This  outer  covering  may  be  removed  during  the  passage 
through  the  intestine.  The  shell  affords  high  resistance  to  changes 
in  temperature  and  moisture.  The  contents  are  granular  but  do  not 
divide  into  nuclei  as  in  the  &gg  of  the  ankylostome. 


3ro 


DISEASES  DUE  TO  HELMINTHS 


a,  Ascaris  Itimbyitoiaes;  b,  Trichocephalus  dispar ;  c,  Oxyuris  vertiiicttlaris  ;  c\  c~, 
Ankylosiomum  duodetmk ;  d,  oncosphere  of  Cestode  ;  e,/,g,  various  Fasa'o/tdt?  ;  /i,  Sc/iis- 
ioso»iu»i{?)  haviatohiiiin  (from  foeces) ;  /,  Schis.tosomtim  h^Tmatohittin  (Irom  urine). 


ASCARIASIS  311 

In  warm  and  muisl  soil  a  spiril  embryo  is  seen  in  one  month,  but 
requires  to  be  ingested  by  man  before  hatching  and  developing  into 
the  adult  form. 

The  source  of  infection  is  by  polluted  vegetables,  fruit,  water,  and 
soiled  hands.  The  eggs  ])ass  unaltered  tiirough  the  alimentary  canal 
of  the  house-fl\',  hence  house-flies  are  carriers  (Stiles). 

The  eggs  liatch  out  in  the  small  bowel  where  the  adults  remain  as 
spindle-shaped  yellowish  worms,  the  male  15  to  25  cm.  long  by  3  mm. 
thick.  The  female  is  from  20  to  40  cm.  long.  They  look  very  like  the 
ordinary  ground  worms.  The  male  carries  two  spicules  posteriorly, 
and  there  are  aboul  seventv  papillcC  around  the  cloaca. 

The  vulva  of  the  female  is  at  the  junction  of  the  anterior  and  middle 
thirds  of  the  body. 

The  eggs  are  tisuallv  in  the  small  intestine  but  have  been  seen  post 
mortem  in  the  stomach,  oesophagus,  nose,  larynx,  trachea  and  bronchi, 
more  rareh'  in  the  li\-er,  pancreatic  duct  and  vermiform  appendix. 

SYMPTOMATOLOGY. 

Symptoms  are  often  nil. 

Skin  eruptions  and  irritation  ma}^  be  present. 

If  manv  are  present  there  ma)'  be  signs  of  toxemia  or  intestinal 
obstruction.  Odd  worms  may  wander  in  many  places,  when  -the 
symptoms  are  according  to  the  mechanical  obstruction  caused,  as  when 
one  passes  into  the  stomach,  vomiting  may  set  in. 

Passes  into  the  appendix,  inflammation  of  that  organ  arises, 
,,  ,,       large  gut,  an  ulcer  may  be  perforated, 

,,       bile  duct,   an  abscess  may  result, 
,,       duct  of  Wii"sung,  pancreatic  instifficiency  and  death, 
,,  ,,        nose,   itching  and  discharge. 

They  have  caused  obstruction,  perforation,  peritonitis  and  death 
(Prasad). 

In  searching  the  faeces  for  eggs  one  must  remember  that  :  — 
The  eggs  may   have  an   albuminous  coating,   or 
They  may  be  decorticated,  or 
They  may  be  unfertilized,  or 

They  may  have  become  embr^'os,  each  stage  presenting  a  different 
picture. 

TREATMENT. 

Give  santonin,  grains  i  to  3,  each  morning  for  three  days. 
Accompany  this  by  calomel  in  equal  doses. 

For  children  give  one-sixth  of  a  grain  of  each  for  each  year  of  life 
for  three  days. 

Repeat  the  treatment  after  one  week  if  the  eggs  are  still  present. 
Santonin  in  excess  may  cause  yellow  blindnt-ss. 


312 


DISEASES  DUE  TO  HELMINTHS 


OXYURIASIS. 
THE  PARASITE. 

The    Oxyuris    vermicularis   or    thread-worm    is    world-wide    in    its 
distribution  and  occurs  only  in  man. 


M 


A,  male  and  B, 
female,  of  Oxyu- 
ris vermicularis. 

5/1- 


'Si^-fpiW 


On  the  left,  female ;  on  the 
right,  male.  A,  anus;  M, 
mouth  :  V,  vulva.  Greatly 
enlarged.     (After  Ciaus.) 


Oxyitiis  vermicu- 
laris :  egg  freshly  de- 
posited, with  tadpole- 
like embryo.     X  640. 


Oxyuris  vermicu- 
laris :  egg  twelve 
hours  after  deposition, 
with  nematode- like 
embryo.      x  640. 


The  male  is  3  to  5  mm.  long  and  the  female  9  to  11  mm.  long. 

They  live  in  the  lower  part  of  the  small  intestine  but  the  gravid 
females  migrate  to  the  caecum,  colon  and  anus.  The  males  die  after 
copulation. 

The  eggs  are  given  off  in  the  gut  and  measure  30  by   20  ^l■ 

They  have  a  thin  shell  and  contain  a  well  developed  embryo  when 
the  egg  is  passed  in  the  fasces.     These  eggs  escape  and  are  re-intro- 


ANKYLOSTOMIASIS  313 

duced  upon  fruits  and  vegetables.  The  Qgg  capsule  is  dissolved  in  the 
stomach,  the  embryo  passes  to  the  small  intestine,  grows  and  becomes 
mature  in  fourteen  days  and  then  copulation  takes  place. 

The  adult  worm  is  a  fine,  minute,  thread-like,  round  worm  with  a 
long  bulbous  oesophagus  and  transversely  striated  cuticle.  The  male 
is  coiled  up  at  the  posterior  end  and  carries  one  spicule. 

The  female  is  straight  and  the  posterior  end  tapers  to  a  point. 

SYMPTOMATOLOGY. 

Irritation  about  the  anus  is  common. 
One  often  meets  with  nocturnal  enuresis  and  insomnia. 
Entero-colitis  and  slight  fever  are  rare. 
Nasal  irritation  is  uncommon. 

The  worms  may  cause  vaginitis  in  girls  and  masturbation  in  both 
sexes. 

TREATMENT. 

To  kill  the  young  forms  use  santonin  and  calomel  as  for  Ascaris. 

To  kill  the  gravid  females  give  rectal  injections  of  quassia,  alum, 
one  drachm  to  one  pint,  or  of  salt,  two  drachms  to  one  pint. 

For  rectal  irritation  or  vaginitis  give  diluted  mercurial  ointment, 
one  in  four.     Iodoform  or  napthalin  suppositories  may  be  used. 

ANKYLOSTOMIASIS. 
DEFINITION. 

This  is  a  toxaemia  passing  to  a  progressive  anemia  caused  by  the 
Ankylostome  duodenale  and  the  Necator  americanus  associated  with 
fatty  degeneration  of  the  heart,  liver,  kidneys,  and  of  the  intestinal 
mucosa. 

DISTRIBUTION. 

The  disease  is  found  wherever  there  is  moisture  and  a  suitable 
temperature  for  the  growth  of  the  parasite. 

It  is  present  in  America,  Africa,  Asia,  Australia,  New  Guinea,  Fiji, 
and  in  the  mines  of  Cornwall  and  Belgium. 

It  was  taken  to  the  United  States  by  African  slaves. 

In  Porto  Rico  70  per  cent,  of  the  people  are  infected  and  30  per 
cent,  of  the  death  rate  is  due  to  this  cause. 

In  the  Army  of  the  Southern  States  6  per  cent,  were  carriers. 

In  the  mills  of  the  Southern  States  12 '6  per  cent,  were  carriers. 

In  Java  97  per  cent,  of  the  population  is  infected.     ' 

THE  PARASITE. 

This  is  the  Ankylostome  duodenale.  (Also  the  Necator  americanus 
as  it  gives  rise  to  similar  svmptoms.) 


314 


DISEASES  DUE  TO  HELMINTHS 


The    disease    was    perhaps    known    and    treated    bv    the    ancient 
Egyptians  1,550  years  B.C. 


U 


WHl 


VI 


»!,/,  male  and  female  Ankylostomes  :   a,  head  of  Ankylostovium  ducknale ; 
b,  head  of  Necator  americamis. 

It  was  rediscovered  by  Dubini  in  Milan,  a.d.   uS^cS. 

The  parasite  is  a  white  cylindrical  worm  living  in  the  upper 
intestine,  the  jejunum  chiefly,  retaining  its  position  with  its  four 
hooks  and  two  conical  teeth,  which  are  carried  about  the  mouth. 


ANKYLOSTOMIASIS 


315 


The    disease    was    perhaps    Icnown     ;incl     treated    b\'    the    ancient 
Egyptians   1,350  years  B.C. 


B 


A  B 

A,   A,  head  and   tail  of  male,  Aiicylostoina  duoJenale ;  v.,   B,  head 
and  tail  of  male  Necator  americanus  ;  x,  x,  dorsal  rays. 


Ancylostoiiia  duodenale :  eggs  in  different  siages  of  development,     a  to  c,  in  fiesh  fiieces  ; 
d,  conlaining  a  larva,  only  in  old  faeces.      X    336.     (After  Looss.) 


Two  long  and  slender  spicules  can  often  be  seen  projecting  through 
the  opening  of  this  bursa. 


3i6  DISEASES  DUE  TO  HELMINTHS 

The  female,  12  to  13  mm.  long,  has  the  vulva  at  the  junction  of 
the  middle  and  hinder  parts  of  the  body,  so  that  when  copulation 
takes  place  the  worm  looks  like  the  Greek  letter  gamma  7. 

LIFE-HISTORY. 

The  adults  live  in  the  jejunum,  where  the  females  lay  their  eggs. 
These  eggs  are  colourless,  with  a  thin,  plain  double  shell,  the  cellular 
contents  being  separated  from  the  shell  b)-  a  clear  space.  During  its 
passage  through  the  intestine  the  cellular  mass  divides  into  two,  then 
four  parts,  and  is  usually  seen  in  this  form  in  the  faeces.  With 
sufficient  air,  water  and  heat  the  embryo  forms  in  twenty-four  hours, 
escapes  from  the  shell,  and  begins  to  feed  on  faecal  material.  Larvae 
measure  from  200  to  250  fi  by  15  to  17  /a. 

Ecdysis  is  completed  in  four  to  six  days  in  the  tropics;  the  larvae 
then  ceases  to  grow.  It  can  remain  alive  in  this  condition  for  months, 
living  on  the  food  in  its  own  cells.  The  larva  may  be  quite  active, 
swimming  or  climbing  to  any  other  suitable  place. 

It  enters  the  hair  follicles  of  man,  causing  "  ground  itch,"  and  may 
even  penetrate  gloves,  paper  and  boots  in  order  to  reach  the  skin. 
Thence  it  passes  to  the  lymphatics  and  venous  blood-vessels.  Some 
of  them  reach  the  right  heart  and  the  lungs,  whence  they  pass  from 
the  capillaries  to  the  alveoli  along  the  bronchioles,  bronchi,  trachea 
and  larynx  to  the  oesophagus,  stomach  and  intestines,  where  they 
remain.  This  occupies  from  seven  to  ten  days,  during  which  time 
several  ecdyses  take  place.  In  eight  days  these  larvae,  3  to  5  mm. 
long,  attain  maturity.  In  fourteen  to  sixteen  days  copulation  has  taken 
place,  and  the  eggs  are  seen  in  the  fccces. 

The  whole  cycle  takes  eight  to  ten  weeks. 

Sambon  says  that  when  the  larv^  are  in  the  lungs  they  pass  from 
the  pulmonary  capillaries  to  the  pulmonary  veins  into  the  general 
blood-stream,  and  hence  into  the  mucosa  of  the  jejunum,  which  they 
pierce,  and  so  enter  the  lumen  of  the  bowel. 

He  believes  that  those  seen  by  Loos  in  the  respiratory  tract  are 
stray  ones.  Perhaps  both  are  correct,  but  experience  has  shown  that 
the  great  majority  pass  as  Loos  has  described.  Some  may  enter 
directly  by  the  mouth,  as  when  miners  eat  their  food  with  soiled  hands. 

In  order  to  grow  the  larvse,  place  a  thin  layer  of  fseces  in  a  Petri 
dish  and  a  piece  of  moistend  blotting-paper  on  the  top.  The  worms 
will  grow  in  two  to  three  days  and  come  upon  the  top  of  the  blotting- 
paper,  where  they  can  be  well  examined. 

Keep  the  paper  moist ;  later  breathe  on  the  paper ;  this  will 
stimulate  movement. 

For  mounting  them,  embed  in  gh'cerin  and  egg-white  smear,  treat 


ANKYLOSTOMIASIS  317 

with   absolute   alcohol,    wasli    dut   glycerine,    and    stain    with    hsematin 
and  eosin. 

SYMPTOMATOLOGY. 

Clinical  Course. 

Papules  or  vesicles  may  form  v/here  the  larv«  enter,  perhaps  due 
to  the  pus  cocci  introduced.  This  is  known  as  "  ground  itch  "  or 
"bunches."  A  leucocytosis  and  an  eosinophilia  can  be  seen  under 
the  microscope  before  other  symptoms  are  manifest.  The  first 
symptoms  generally  observed  are,  however,  pallor,  weakness,  breath- 
lessness,  oedema,  general  or  local,  emaciation  perhaps  concealed  by 
the  oedema.  Flatulence,  dyspepsia,  nausea,  vomiting,  epigastric  pain, 
constipation  or  diarrhcjca ;  later  in  tlie  final  stages  there  may  be  a 
general  anasarca. 

One  finds  the  ova  in  the  stools  with,  sometimes,  blood  and  mucus, 
also  Charcot-Leyden  crystals. 

In  some  cases  there  is  a  perverted  appetite,  perhaps  due  to  mental 
disturbance  (geophag\'). 

Impotence  is  common,  68  per  cent,  of  Sandwith's  cases. 

Puberty  is  delayed  in  both  sexes.  It  arrests  growth  and  develop- 
ment generally. 

Lemann  noticed  that  infantilism  was  present  in  voung  hookworm 
patients  of  the  Southern  United  States.  He  finds  that  the  disease 
produces  :  — 

(i)  A  general  retardation  of  skeletal  changes. 

(2)  A  general  retardation  of  growth,  symmetrical  and  harmonious. 

(3)  A  failure  of  development  of  the  genitals  as  well  as  the  absence 
of  secondary  sexual  characteristics. 

(4)  A  general  slowness  and  dullness. 

THE  BLOOD  EXAMINATION. 

The  volume  of  blood  is  increased,  causing  dilatation  of  the  heart 
and  hjemic  bruits  at  the  apex.  Coagulation  is  diminished,  the  blood 
readily  spreading  over  the  skin  when  punctured.  The  blood  condition 
predisposes  to  palpitation,  and  a  quick,  thready,  dicrotic  and  inter- 
mittent pulse. 

The  red  cells  are  markedly  diminished ;  one  patient  had  but  930,000 
and  recovered.     The  haemoglobin  may  be  as  low  as  15  per  cent. 

There  are  many  changes  in  the  red  cells,  but  they  are  more  uniform 
than  in  pernicious  anaemia.  One  finds  poikilocytes,  megalocytes, 
normoblasts  and  megaloblasts.  Polychromasia  is  not  infrequent. 
The  eosinophilia  is  from  10  per  cent,  to  50  per  cent.,  sometimes  well- 
marked  in  children,  but  may  be  absent  in  adults  (Low). 

The  leucocytes,  total  count,  vary  from  20,000  to  50,000  per  cm. 


3i8  DISEASES  DUE  TO  HELMINTHS 

The  disease  is  often  fatal  during  parturition  and  during  operative 
treatment.     Sometimes  a  low  fever  is  present,  but  this  is  the  exception. 

The  aucemic  condition  is  probably  caused  by  a  toxin  excreted  by 
the  Axorms  which  passes  into  the  circulation  through  the  wound  made 
in  the  mucosa  of  the  jejunum,  together  with  the  actual  blood  lost  at 
the  site  of  the  bites.  The  condition  is  aggravated  undoubtedly  by 
septic  absorption  from  the  same  foci. 

Post  mortem,  }'ellow  pigments  and  iron  granules  are  found  deposited 
in  the  liver  and  kidneA'  cells  in  bad  cases. 

COMPLICATIONS. 

Albuminuria,  present  in  80  per  cent,  of  Sandwith's  cases. 
General  oedema  may  be  present. 

Any  inlercurrenl  disease,  as  d\senlery,  which  is  common. 
Pregnane}'  or  operatiA-e  procedure  are  serious  complications.     The 
former  cases  die  of  heart  failure  just  before  the  child  is  born. 
TJiere  is  a  tendency  to  post-partum  hccmorrhage. 
Cardiac  failure  is  common. 

PROPHYLAXIS. 

The  ankylostome  embryos,  wlien  passed  under  good  conditions  for 
them,  can  survive  and  develop  as  free  living  larvae  awaiting  access 
to  man  in  order  to  complete  their  development,  hence  prophylaxis  is 
important  and  may  be  summarized  thus  :  — 

(1)  Educational. 

The  instruction  of  rich  and  poor  a\  ilh  regard  to  methods  of  infection, 
symptoms,  treatment  and  prophylaxis. 

(2)  Public. 

Search  for  and  treat  carriers,  aucemic  people  and  those  with  skin 
eruptions. 

The  provision  of  sanitar)-  conveniences  which  should  be  kept  in 
good  condition. 

(3)  Private. 

Protection  of  the  feet  bv  boots,  &c. 

The  proper  cleaning  of  hands  before  meals. 

Immediate  treatment  of  eruption  on  hands  and  feet. 

TREATMENT. 

1  he  indications  are  to  expel  the  worms  and  to  aid  blood  formation. 
There  are  four  main  lines  of  treatment  as  follows  :  — 

(1)   Thymol  Treatment. 

Put  the  patient  in  bed  on  starvation  diet  for  two  days. 
Exclude  all  other  possible  ailments. 


ANKYLOSTOMIASIS  319 

Alcohol   is  strictly  forbidden  as  it  dissolves  the   thymol   and  may 
produce  a  fatal  result. 

Some  ofive  str\(^hnine,  but  this  is  verv  soluble  with  th\mol  and  in 
anv  case  should  not  be  given  b}-  mouth. 

Give  a  saline  purge  at  the  end  of  the  second  day. 

All  food  prohibited  during  the  thymol  treatment. 

Give  thvmol,  one  to  two  grams  next  morning. 
,,  ,,  ,,  two  hours  later. 

,,  ,,  ,,  two  hours  later. 

Give  a  saline  aperient  four  hours  after  the  last  dose  of  thymol. 

Castor  oil  must  not  be  given  as  thvmol  is  soluble  in  it. 

Sandwiih   recommends  strychnine  injections  before  the  treatment. 

Do  not  give  thymol  to  patients  with  fatty  hearts,  visceral  disease 
or  with  an  anaMiiia  below   1,500,000  red  cells  per  cm. 

(2)  The  Eucalyptus  Treatment. 

The  preliminary  two  days  as  above. 

Give  a  saline  purge  at  6  p.m. 

Xext  morning  at  7  a.m.  and  7.30  a.m.  give  the  following  mixture  :  — 

^     Olei  eucalypti     ...         ...         ...         ...         ...     15  minims 

Chloroformis       ..  ...  ...  ...  ...     22       ,, 

Olei  ricini  ...         ...         ...         ...         ...     half  a  drachm 

This  amount  to  be  gi\-en  on  each  occasion. 

For  children  divide  tlie  whole  dose  into  three  parts  and  give  each 
pan  t\\eniy  minutes  later  than  the  preceding.  The  total  amount  being 
one  half  ihat  of  the  adult. 

(3)  The  Beta-naphthol  Treatment. 

The  preliminarA'  treatment  as  before. 
The  beta-naphthol  must  be  fresh  and  kept  cool. 
It  is  a  popular  remech'  \\\i\\  the  I'rench. 

]^     Beta-naphthol,  finely-powdered     ...         ...         ...     30  grains 

Mucilaginis  tragacanthae    ...         ...  ...  ...        i  drachm 

Aciiiifi  menthfe  piperita       ...         ...         ...  ....       5  drachms 

Give  a  purge  overnight. 

At  6  a.m.  give  full  dose  as  above. 

At  8  a.m.  repeat. 

At  10  a.m.  repeat. 

At  12  noon  give  a  saline  purge. 

(5')   The  Oleum  Chenopodii  Treatment  (Dav  and  Ferguson). 
Preliminary  treatment  as  above. 

Give  the  above  oil  in  three  doses  of  16  drops  on  sugar  at  two  hour 
intervals. 

Give  castor  oil  purge   17  grm.  with  chloroform  3  grm. 


320 


DISEASES  DUE  TO  HELMINTHS 


This  oil  has  a  disagreeable  flavour  and  is  expensive. 

In  any  of  these  methods  three  repeated  treatments  may  be  necessary, 
in  which  cases  allow  an  interval  of  four  to  seven  days. 

In  some  cases  it  is  difficult  to  clear  out  all  the  worms  even  with  the 
repeated  courses. 

The  ana?mia  should  be  treated  on  general  lines. 

Iron,  grains  30  or  more  should  be  given  daily. 

Reduced  iron,  ferric  perchloride,  ferrous  sulphate,  iron  carbonate 
(Blaud),  and  the  ammonia  citrate  are  useful  in  the  order  named. 

Arsenic  and  digitalis  can  also  be  given. 

Points  of  Difference  between  the  Ankylostome  duodenale  and 

THE  Negator  americanus. 


A.  duodenale 

The  worm  is  thicker  and  longer 
The  bend  of  the  neck  is  slow 
The  mouth  capsule  is  large  and  thick 
The  oesophagus  is  long  and  tubular 
The  teeth  are  small  and  shallow,  with  a 

large  brownish  pear-shaped  hook 
There  are  two  separate  spicules  in  the 

male 
The  dorsal  ray  of  the  bursa  has  three 

prongs 


N.  americanus 

The  worm  is  thinner  and  shorter 

The  neck  bend  is  sharp 

The  mouth  capsule  is  small  and  thin 

The  oesophagus  is  bent  and  bulbed 

The  teeth  are  large  pointed,  spheroidal  and 

colourless 
There  is  one  spicule  in  the  male 

The  dorsal  ray  of  the  bursa  has  two  prongs 


Table  indicating  briefly  the  Mode  of  Infection  by  Helminths. 

(After  Daniels.) 


Worm 

Leave  Man 

Life  ouiside  Man 

Re-enter  Man 

Ascaris     lum- 

As  eggs  with  un- 

Development of  egg  con- 

Eggs containing  embryos 

b  r  i  CO  i  des 

developed  con- 

tents change  into  em- 

are swallowed,   usually 

and  Tricho- 

tents 

bryo    in    water   or    on 

with  food 

c  e  p  h  a  1  u  s 

earth 

dispar 

Oxyuris      ver- 

Adults  leave  rec- 

Eggs undergo  little  or  no 

Eggs  containing  embryos 

micularis 

tum  and  deposit 

further      development, 

are  swallowed — usually 

eggs  on  skin 

as    embryo    is    already 

remtroduced     into    the 

formed 

same  patient 

Strongyloides 

Embryos    passed 

Develop,  become  sexually 

Enter  man   with  food,  or 

intestinalis 

with  faeces 

mature,    and    multiply 

in  any  substance  con- 

sexually 

taminated  with  infected 
earth,  or  through  the 
skin 

Ankylostome 

Eggs  ;  division  of 

Embryos  hatch  out    and 

Embryos  re-introduced  by 

duodenale 

egg       contents 

develop  to  a  consider- 

the    mouth,     probably 

aiid  Necator 

has  commenced 

able    extent    in    moist 

in    food     contaminated 

americanus 

earth 

with  earth.  Also  enter 
through  the  unbroken 
skni 

Trichina  spir- 

Embryos develop 

Only    in    animals    eating 

Usually  from  eating  pork 

alis 

to  their  limit  in 

the  infected  flesh 

containing        encysted 

the    muscle    of 

larvas 

the  host 

F.  bancrofti... 

Embryos     ab- 

Embryos  develop  in  mos- 

Larvae discharged  by  mos- 

stracted     with 

quito,  into  larvae    with 

quitoes     on     man    and 

blood  by  mos- 

an  alimentary  canal 

enter  through    the   un- 

cjuiloes 

broken  skin 

PRESERJ\iTION  AND  EXAMINATION  OF  HELMINTHS    321 


Worm 


F.  loa 

F.  medinensis 

T.  saginata  ... 

T.  solium 

T.   echinococ- 
ciis 


'J'rematodes, 
both  Fascio- 
lidge        and 
Paramphis- 
tomidae 


Schistomidte 


Leave  Man 


By  Chrysops  dim- 
idiata 

Embryos  dischar- 
ged into  water 


Oncospheres 

Oncospheres 

"Hydatid  cysts." 
Does  not  leave 
man,  who  is  an 
accidental  host 

Eggs  with  unde- 
veloped ovum 
in  feces,  or  in 
one  instance  in 
sputum 


Eggs  with  unde- 
veloped ciliated 
embryo,  mira- 
cidium,  with 
urine  or  feces 


Life  outside  Man 


Similar  development  in 
salivary  glands  of 
Chrysops 

Embryos  swallowed  ?  by 
chrysops  and  there 
develop  to  a  certain 
extent 

In  muscle  of  cattle  (Cys- 
ticercus  bovis) 

In  muscle  of  pig  (Cys- 
ticercus  celluloste) 

Adult  worm  in  intestines 
of  dogs,  &c.,  who  derive 
infection  from  food, 
offal  from  slaughter- 
houses, &c. 

Ovum  develops  in  water, 
embryo  enters  molluscs 
or  fish  and  there  multi- 
plies asexually,  produ- 
cing ultimately  young 
flukes,  cercariie,  encys- 
ted on  vegetables  or 
free  swimming  in  water 

Embryos  escape  from  egg 
when  urine  or  fasces 
are  diluted.  Further 
development,  if  any, 
outside  man,  is  un- 
known 


Re-enter  Man 


Cyclops  containing  devel- 
oped larvat  swallowed 
by  man 

Eating  beef  containing 
Cysticercus  bovis 

Eating  pork  containing 
Cysticercus  cellulosa" 

By  swallowing  oncosph- 
eres from  fteces  of 
infected  dogs 


Swallowed  by  man  on 
vegetables  or  in  water 
or  in  undercooked  fish 


Probably  enters  through 
the  skin  during  bathing 


THE  PRESERVATION  AND  EXAMINATION  OF 
HELMINTHS.     (After  Daniels.) 

SMALL  NEMATODES. 

Preservation. 

(i)  Shake  up  the  live  worms  in  a  i  per  cent,  salt  solution,  to  remove 
mucus. 

(2)  Kill  by  dropping  into  boiling  70  per  cent,  spirit  and  allow  to 
cool. 

(3)  Transfer  to  fresh  70  per  cent,  spirit  for  storage. 

For  Clearing  and  Mounting. 

(i)  After  treating  with  stages  i  and  2  as  above,  transfer  to  a  mixture 
composed  of  70  per  cent,  spirit,  95  parts  with  5  parts  of  pure  glycerine. 

(2)  Evaporate  in  a  water  or  paraffin  batli  until  all  the  alcohol  has 
gone. 

(3)  Mount  in  glycerin  jell  v. 

(4)  Ring  with  gold  size. 

Examination  without  Mounting. 

(i)     Take   from   the   70   per   cent,    spirit    and  place    in    methylated 
spirit. 

21 


322  DISEASES  DUE  TO  HELMINTHS 

(2)  Transfer  to  colourless  cold  tar  creosote,  allow  to  clear,  and 
examine  in  that  fluid. 

After  the  examination  is  concluded  pass  through  methylated  spirit 
back  to  70  per  cent,  spirit  as  before  to  store. 

LARGE  NEMATODES. 

These  are  treated  in  the  same  way  as  small  ones  except  that  they 
cannot  be  cleared  and  mounted  by  the  glycerine  method. 

SMALL  TREMATODES. 

Preservation. 

(i)  Place  alive  in  a  test  tube  one-third  full  if  i  per  cent,  saline,  and 
shake  vigorously. 

(2)  Add  to  the  test  tube  rapidly  an  equal  quantity  of  saturated 
solution  of  sublimate. 

(3)  Shake  vigorously  for  three  minutes. 

(4)  Transfer  to  70  per  cent,  spirit  to  store. 

Examination  without  Mounting. 

As  for  small  nematodes. 
In  order  to  make  stained  and  mounted  specimens  :  — 
(i)  Transfer  from  70  per  cent,  spirit  to  a  i  per  cent,  solution  of  alum 
to  which  is  added  a  little  ha^matoxylin,  until  the  whole  is  a  light  claret 
colour.  The  ha^malum  solution  (ha?matin,  2*5  grm.,  absolute  alcohol 
50  c.c,  alum  50  grm.  or  to  saturation,  water  1,000  c.c.)  diluted  with 
distilled  water  gives  good  results,  and  so  does  a  weak  solution  of 
carmine,  but  in  that  case  longer  staining  is  required.  Leave  in  this 
one  to  four  days. 

(2)  Decolorize  slighllv  with  ^  per  cent,  acid  water. 

(3)  Wash  well. 

(4)  Dehydrate  with  spirit  and  oil  of  cloves. 

(5)  Pass  through  zylol  and  mount  in  balsam. 

LARGE  TREMATODES. 

Preservation. 

(i)  Drop  alive  in  a  i  per  cent,  saline  and  shake  vigorously. 
(2)  Add  formalin  (commercial)  to  this  to  make  about  a  10  per  cent, 
solution,  and  shake  vigorously  until  death  occurs. 

The  specimens  can  be  kept  in  10  per  cent,  formalin. 

Examination. 

This  is  best  done  by  embedding  and  cutting  sections. 
To  mount  Specimens  whole. 

(i)  Press   between    two   slides  wliilst   alive,    and   drop   into   70  per 
cent,  spirit. 

(2)  Stain  and  clear  as  in  small  specimens. 


HIRUDINIASIS  323 

CESTODES. 

Preservation. 

(i)  Shake  gently  in  i  per  cent,  saline. 

(2)  Add  formalin  to  this  to  make  a  10  per  cent,  solution  and  shake 
pfentlv  until  thev  die. 

The  specimens  can  be  stored  in  10  per  cent,  formalin. 

To  stain  and  mount  Segments. 

(i)  Place  alive  in  weak  glycerin,  faintly  coloured  with  carmine,  and 
leave  until  stained,  or  dilute  hiemalum  may  be  used. 

(2)  Press  between  two  slides  and  drop  into  methylated  spirit. 
They  should  remain  in  this  for  twenty-four  hours. 

(3)  Remove  the  pressure  and  place  the  segments  in  fresh  methylated 
spirit  for  an  hour  or  so. 

(4)  Clear  in  oil  of  cloves. 

(5)  Pass  through  zylol  and  mount  in  balsam. 
Creosote  may  be  used  to  clear  instead  of  oil  of  cloves. 

The  Preservation  of  Helminth  Ova  in  Faeces. 

Method  (i). 

Alcohol,  70  per  cent.,  with  5  per  cent,  glycerine  added,  is  raised  to 
boiling  point. 

Fluid  faeces,  or  faeces  made  fluid  by  dilution  with  saline,  are  poured 
into  the  boiling  alcohol,  stirred,  and  then  set  aside  to  inspissate  in  a 
warm  place.  When  the  fasces  have  become  a  sticky  mass,  sufficient 
pure  glycerine  is  added  to  make  a  soft  paste  (Leiper). 

Method  (2). 

To  fluid  faeces  add  equal  parts  of  Langeron's  lactophenol.  This 
latter  consists  of  carbolic  acid  one  part,  lactic  acid  one  part,  glycerin 
two  parts,  and  water  one  part. 

Shake  vigorously. 

This  mixture  will  form  a  pasty  jelly  and  will  keep  indefinitely. 

A  permanent  preparation  can  be  made  at  any  time  by  stirring  a  small 
portion  into  a  loop  of  melted  glycerin  jelly  on  a  slide,  a  cover  glass  is 
placed  on  the  jelly,  and  when  this  is  set  the  preparation  is  completed  by 
sealing  with  gold  size  (Leiper). 

HIRUDINIASIS. 
DEFINITION. 

An  invasion  of  the  mouth,  nose,  pharynx  and  larynx,  or  an  afi'ection 
of  the  skin  by  leeches,  a  group  of  unsegmented  worms  allied  to 
Chastopoda. 


324 


DISEASES  DUE  TO  HELMINTHS 


>ETIOLOGY. 

Leeches  are  troublesome  chiefly  in  the  Near  East,  Ceylon,  Philippine 
Islands,  Japan,  Australia  and  the  Asiatic  and  the  American  jungle. 
There  are  many  species  but  few  readily  attack  man. 

There  are  the  :  — 

(i)  Land  leeches  or  Hctmadipsa.   These  live  in  the 
damp  jungle  country,   as  the   ILemadipsa  ceylonica 
of  Ceylon.     They  rest  upon  twigs  and  leaves  await- 
ing the  presence  of  some  mammal  to  attack. 
'1'  '^1\  They  are  very. active  and  are  able  to  pass  through 

very  narrow  orifices  such  as  the  lace-hole  of  a  boot. 
Their  bite  is  painless  and  the  first  indication  of 
their  presence  may  be  that  the  boot  is  full  of  blood. 
In  such  cases  there  is  often  some  local  inflammation 
and  sloughing. 

(2)     Water   leeches,  or   Limnatis.     These    live    in 
springs   like   the   Limnatis   nilotica   and  are   trouble- 
some to  man  when  he  drinks  the  spring  water.     The 
..Ml  thirsty  traveller  at  dusk  is  usually  the  victim. 

The  salivary  glands  of  these  parasites  open  into 
the  mouth  and  secret  a  fluid  which  prevents  the 
coagulation  of  the  blood 

When  it  has  gorged  itself  it  drops  off  but  the 
bleeding  continues. 

The  pharynx  of  the  leech  has  a  powerful  mus- 
cular  sac  which  bv  contracting  and  dilating  forms  a 
sucking  pump. 

The  blood  is  stored  up  in  the  crop  and  its  caecal 
diverticula  and  onlv  a  little  is  used  daily  for  food. 


^> 


The  internal  organs 
of  the  leech.  The 
creature  has  been 
opened  from  the 
dorsal  surface,  and 
part  of  the  intestine 
has  been  removed. 
The  testicles,  with 
vas  deferens,  may  be 
seen  between  the 
blind  ducts  of  the 
intestine  ;  beyond 
these  on  either  side 
the  segmental  organs. 
The  female  genital 
organs  are  in  front 
of  the  most  anterior 
pair  of  testicles. 
(After  Kennel.) 


SYMPTOMATOLOGY. 

This  is  according  to  the  variety  and  position  of 
the  leech. 

There  may  be  bleeding  from  the  nasal  or  buccal 
cavities  which  may  indicate  that  the  leech  or 
leeches  are  anvwhere  in  the  respiratory  tract  to  the 
trachea  and   the  deglutition   tract   to  the  stomach. 

There  may  be   irritating  cough  and  dyspnoea. 


Bleedinp-  from  the  skin  with  land  leeches. 

O 


Anaemia. 


TREATMENT. 

Saline  solution  will  loosen  them  when  it  is  possible  to  apply  it. 
Saline  solution  upon  the  clothing  or  boots  of  jungle  travellers  is 


POROCEPHALOSIS  325 

protective.  A  "  clip  in  the  briny"  witJi  one's  clothes  on  before  com- 
mencing a  march  is  sufficient  in  most  cases. 

Cotton  wool  soaked  in  30  per  cent,  cocaine  applied  to  the  parasite 
will  paralyse  it  and  cause  it  to  drop  off,  but  if  the  leech  is  in  the  larynx 
the  patient  must  be  held  with  the  head  downwards  or  the  leech  will  drop 
into  the  trachea. 

Leeches  should  not  be  removed  forcibl}-. 

The  gastric  juice  is  said  to  kill  them. 

Leeches  are  not  known  to  carrv  disease. 


POROCEPHALOSIS. 

There  are  twenty  known  species  of  Porocephalus,  two  of  which 
occur  in  man.  They  belong  to  the  parasitic  Arachnoidea  and  Lingua- 
tulida. 

They  have  elongated  vermiform  bodies  and  a  continuous  coelom. 

The  female  is  9  to  12  cm.  long,  the  male  3  to  4*5  cm.  long  by  2  to 
4  mm.  broad,  with  twenty-six  to  thirt\'  rings. 

They  are  commonly  found  in  the  nasal  cavities  and  lungs  of  pythons 
and  snakes.  The  eggs  probably  pass  from  these  reptiles  into  water  and 
thence  into  man.  These  eggs  develop  into  larvae  and  nymphas  which 
may  then  become  encysted  in  the  lungs  or  the  liver  of  man,  or  thev 
may  move  freely  in  the  small  intestine  and  even,  at  times,  enter  the 
peritoneal  cavity. 

The  P.  armillatus  and  the  P.  moniliformis  affect  man.  The\'  are  a 
bright  lemon  yellow  colour  when  fresh. 

DISTRIBUTION. 

The  P.  armillatus  is  found  in  Africa  only.  Chiefly  in  Egvpt,  West 
Coast  and  the  Congo. 

The  P.  moniliformis  is  found  in  Ja\a,  Philippines  and  India. 

PATHOLOGY. 

The  larvae  are  found  coiled  up  in  cysts  of  the  liver  and  lungs. 

Here  they  become  nymphfe,  leave  the  cysts  and  wander  about  the 
body . 

They  may  pass  into  the  lungs  causing  bronchitis  or  broncho- 
pneumonia. 

Or  into  the  peritoneal  cavity  causing  peritonitis. 

Or   into   the   intestinal    tract   causing   diarrhoea. 

SYMPTOMATOLOGY. 

The  distinctive  symptoms  are  not  appreciated  until  they  become 
terminal.     Then  one  has  emaciation  and  weakness  associated  with  an 


326  DISEASES  DUE  TO  HELMINTHS 

attack  of  bronchitis  or  pleurisy.  There  may  be  cavities  in  the  lungs 
and  offensive  sputum  which  may  contain  the  parasites.  One  patient 
was  known  to  expectorate  from  75  to  100  of  these  parasites.  The  liver 
is  usually  enlarged. 

The  condition  has  been  mistaken  for  phthisis. 

There  is  no  known  effective  treatment. 


SECTION   IV. 
DISEASES  OF   UNCERTAIN   ^ETIOLOGY. 

PELLAGRA. 

BERIBERL 

EPIDEMIC  DROPSY. 

HILL  DIARRHCEA. 

SPRUE. 

PHLEBOTOMUS  FEVER. 

VERRUGA  PERUVIANA. 

YELLOW  FEVER. 

NOTES  ON  THE  STEGOMYIA  CALOPUS   (FASCIATA). 

SPOTTED   FEVER  OF   THE  ROCKY  MOUNTAINS. 

DENGUE  FEVER. 

TYPHUS  FE^VER, 

HEMOGLOBINURIA. 

FAVISM. 

HEATSTROKE. 

SOME  UNCLASSIFIED  FEVERS  AS  :  — 
Japanese  River  Fever. 
Nasha  Fever. 
Pigmentary  Fever. 
Archibald's  Fever. 
Hyperpyrexial  Fever. 
Bacillus  Asiaticus  Fever. 
Double  Continued  Fever. 
The  Macular  Fever  of  Tunisia. 
Low  Intermittent  Non-malarial  Fever. 
Rat-bite  Fever. 
Five-day  Fever. 
Trench  Fever. 

THE   EXANTHEMATA. 

TROPICAL  HAY  FEVER. 

TROPICAL  NEURASTHENIA. 

ENDEMIC  PERIPHERAL  FEVER. 

ENDEMIC  PARALYTIC  VERTIGO. 

LATAH. 

AMOK. 

ENDEMIC  FUNICULITIS. 

EPIDEMIC  GANGRENOUS   RECTITIS. 


328  DISEASES  OF  UNCERTAIN  ETIOLOGY 

INFANTILE  BILIARY  CIRRHOSIS, 

GOITRE. 

CLIMATIC  BUBO. 

GOUNDOU. 

BIG  HEEL. 

AINHUM. 

GANGOSA. 

CHAPPA. 

PONOS. 

TROPICAL  LIVER. 

BOOMERANG  LEG. 

WHITMORE'S  DISEASE. 

ONYALIA.  ^ 

AFEBRILE   SPLENOMEGALY 


PELLAGRA  329 

DISEASES    OF    UNCERTAIN     ^ETIOLOGY. 

PELLAGRA. 

(Pellagra — rough  skin;  "  pelle,"  the  Italian  word  for  skin,  "  agra  " 
meaning  rough.) 

DEFINITION. 

A  chronic  endemic  disease  of  unknown  causation  with  cutaneous, 
gastro-intestinal  and  nervous  symptoms  which  usually  recur  in  the 
spring  and  autumn. 

DISTRIBUTION. 

Perhaps  Francis  of  Assisi  suffered  from  it. 

It  was  well  known  by  medical  men  to  be  widespread  in  Italy  at  the 
beginning  of  the  eighteenth  century. 

Casal  discovered  it  in  Spain  in  1735. 

Also  present  in  Portugal  and  France. 

Some  of  Napoleon's  soldiers  became  infected  in  Italy. 

It  is  still  very  prevalent  in  Austria  and  Hungary. 

Roumania  has  200,000  cases  (Babes). 

Reported  in  the  British  Isles  in  i860.  In  Scotland  and  the  Shet- 
lands  in  1909. 

It  is  also  found  in  Egypt,  West  Indies,  Mexico,  North  American 
Indians,  India,  Straits  Settlements,  Philippine  and  Sandwich  Islands; 
Africa,  Europe,  Asia,  Oceania,  America,  and  perhaps  is  world-wide. 

It  is  found  chieflv  in  country  places  and  along-  certain  streams,  less 
seldom  in  towns. 

Attacks  most  frequently  appear  during  the  late  springtime  and  the 
autumn.     It  tends  to  disappear  in  the  winter. 

None  are  exempt.     Females  are  attacked  to  males  as  two  is  to  five. 

Jews  are  rarely  affected. 

It  is  tO'  be  noted  that  those  engaged  in  agriculture  appear  to  be 
affected  most. 

ETIOLOGY. 

The  chief  theories  are  :  — 
(i)  The  Deficiency  Theory. 

(2)  The  Maize  Theory. 

(3)  The  Parasitic  Theory. 

(4)  The  Mineral  Acidosis  Theory. 

(1)  The  Deficiency  Theory. 

The  lack  of  some  nitrogenous  complex  in  the  food. 

When  steam-milled  mealie  bread  alone  w^as  supplied  to  prisoners 


330  DISEASES  OF  UNCERTAIN  ETIOLOGY 

in  the  \'ictoi"ia  jail  in  Rhodesia  the  disease  broke  out;  when  hieat, 
vegetables  and  rice  replaced  the  mealie  the  epidemic  ceased,  and  when 
hand-milled  maize  was  obtained  the  improvement  was  "  immediate  and 
almost  magical  "  (Nightingale). 

But 
Pellagra  ma}^  occur  in  people  having  the  best  of  suitable  food. 

(2)  The  Maize  Theory. 
Pro.     (i)  The  liistory  of  maize  production  and  consumption. 

Maize  is  native  to  America,  where  it  has  been  found  in 
the  graves  of  the  Incas.  Columbus  or  his  followers 
introduced  it  to  Europe,  but  it  did  not  grow  well  in  the 
British  Isles,  which  therefore  remained  free  from  the 
disease  until  the  nineteenth  century,  when  maize  was 
imported  in  larger  quantities  and  used  in  the  preparation 
of  cakes,  porridge,  pop-corn  and  whiskey. 
It  grew  well  in  Spain,  Ital}'  and  France,  Avhere  Pellagra 
appeared. 

(2)  In  the  Nile  delta  there  is  plenty  of  maize  and  plenty  of 
pellagra,  but  higher  up  the  Nile  millet  is  used  instead 
of  maize,  and  pellagra  is  found  less  frequently. 

(3)  In  Colombia  it  is  said  to  be  found  only  in  people  who 
take  the  drink  made  from  fermented  maize  called 
"chicha." 

(4)  Maize  is  found  more  or  less  all  over  the  world,  so  is 
pellagra. 

Con.  (i)  There  are  entire  districts  in  Italy  and  Brazil  where  the 
people  have  never  lived  on  maize,  but  where  pellagra  is 
prevalent.  Other  districts  where  bad  maize  is  used 
almost  exclusively  there  is  no  pellagra. 

(2)  Relapses  occur  in  jails  over  long  periods,  five  to  fifteen 
years,  where  maize  is  rigidly  excluded. 

(3)  Pellagra  was  present  in  Europe  before  maize  was  intro- 
duced, e.g.,  the  attack  of  Francis  of  Assisi,  before  the 
time  of  Columbus. 

(4)  Prophylactic  and  curative  measures  based  on  the  maize 
theory  have  yielded  very  little  result.  Progressive 
symptoms  continue  after  absolute  prohibition  of  the 
cereal  (Alberto  Cencelli). 

Various  Maize  Theories. 

The  Photodynamic  Theory  (Raubitschek). 

Pro.     An   exclusive   maize   diet   proves   deleterious   to  white   mice 
and  guinea-pigs  if  such  are  exposed  to  the  sun. 


PELLAGRA  331 

Other  cereals  do  the  same.  It  is  maintained  that  photo- 
dynamic  substances  are  introduced  by  cereals  into  the 
blood.  These  with  sunlight  produce  toxins  and  cause 
pellagra  symptoms.  In  darkness  mice  have  been  cured. 
Cox.  Hirschfelder  searched  the  blood  of  severe  cases  for  the 
photodynamic  substance,  but  failed  to  find  any. 
Pellagra  occurs  in  jet-black  negroes,  whose  pigment  protects 
them  consjderablv  from  the  sun's  rays. 

The  Deficiency  Theory. 
Pro.     Insufficient  protein  in  maize  food. 

Con.     Many  live  on  rice  and  potatoes  which  contain  less  nitrogen 
ratio  than  maize. 

The  Toxicity  Theory. 

Some  claim  that  there  is  an — 

Individual  susceptibility  to  maize  intoxication. 

Others  that  there  are  toxins  produced  in  the  spring  bv  the  germina- 
tion of  maize. 

Others  that  there  are  toxins  generated  in  the  bowel  by  aid  of  the 
B.  coli. 

Others  that  there  are  alkaloidal  and  other  poisons  in  fermenting 
maize. 

The  Infectivity  Theory. 

The  most   popular  view.      The  maize  is  cultivated  and   harvested 
under  unfa\ ourable   conditions,   and   stored    in    damp    places   and   be- 
comes mouldy.     Ilirsch  states  that  after  a  bad  season  cases  increase. 
This  infection  may  be  :  — 

(i)  Func^i  as  Pernicious  glaucum,   Aspergillus,  &c.,  the  fungi 

or  their  toxins. 
(2)  Bacteria  as  B.  solanacearum,  B.  subtilis,  B.  pellagr^e. 

(3)  The  Parasitic  Theory. 

This  is  supported  by  the  Illinois  Commission. 

A.  Vegetable   Parasite,  e.g.,   Tizzoni's  streptobacillus. 

He  claims  to  have  found  it  in  the  blood,  cerebrospinal  fluid, 
and  viscera  of  pellagrins  after  death.     Others  refute  this. 

B.  Animal  Parasites. 

(i)  A  slender  nematode  worm  (Filaridae  alessandrina)  in  drinking 
water. 

(2)  A  phase  of  ama?bic  dysentery  (Long). 

(3)  A  protozoan  infection  spread  by  a  biting  fly  (Sambon). 


332  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

Pro.     Sambon  supports  his  view  c!T;  tlie  basis  of  its  being  protozoan 
because  : — - 
(i)  There  is  a  mononucleosis  present  in  the  blood. 

(2)  There  are  long  intervals  of  quiescence  followed  by  relapse. 

(3)  There  is  a  constant  and  characteristic  topographical  dis- 
tribution. 

(4)  The  symptoms,  course,  duration,  and  morbid  anatomy  are 
similar  to  those  found  in  other  parasitic  diseases. 

(3)  Sambon  found  a  spirochcCte  in  a  bulla  on  the  hand  of  a 
severe  pellagra  case. 
Con.     No  parasite  has  yet  been  found. 

Fluids    from    pellagrins    have    not    reproduced    the    disease 
when  injected  into  other  animals. 

A  biting  fly  is  bhivicd  because: — 

It  is  a  disease  of  rural  districts  essentiallv. 

It  is  in  some  way  related  to  moving  water. 

It  has  a  definite  seasonal  influence,  spring  and  autumn,  which 

coincides  with  the  appearance  of  certain  flies. 

It  affects  labourers  in  the  field. 

It  is  not  contagious  (Goldberger). 

Young  children  and  whole  families  often  are  readilv  affected  in 

an  endemic  centre. 

Sambon  suggests  one  of  the  simulidcv  because: — 
Their  larv^  live  in  running  water. 

They  have  two  seasons,  spring  and  autumn,  when  they  attack 
man  and  beast  in  swarms. 

But 

They  are  not  found  in  the  Xile,  where  pellagra  is  common. 
The  Illinois  Commission  does  not  agree  on  this  point. 

(4)  The  Mineral  Acidosis  Theory. 

The  findings  of  Professor  Alessandrini  and  Scala  of  the  Pellagra 
Commission  of  Rome  may  be  summarized  thus  :  — 

Pellagra  is  strictly  localized  and  limited  to  areas  where  the  water 
drunk  has  almost  exclusively  been  in  contact  with  clav. 

Clay  is  silicate  of  alumina. 

The  action  of  rain  water  upon  tliis  produces  bv  hvdrolvsis  silicic 
acid  and  hydrate  of  alumina  which  pass  into  the  water  in  a  colloidal 
form . 

A  colloidal  silica-alumina  is  formed,  some  as  a  deposit  and  some 
remaining  in  suspension. 


PELLAGRA  333 

The  inp-estion  of  this  latter  causes  a  retenlion  of  salts  in  the  tissues 
resulting-  in  their  excessive  fixation  which,  when  liberated  in  excess, 
causes  the  pathological  lesions  of  pellagra. 

They  aftirm  to  have  considerably  improved,  if  not  to  have  cured, 
cases  bv  muscular  or  subcutaneous  injections  of  neutral  citrate  of 
sodium. 

Dailv  injections  of  a  lo  per  cent,  solution  of  trisodic  citrate  were 
given.     The  acidosis  is  said  to  be  neutralized  by  it. 

PATHOLOGY. 

There  is  an  infiltration  of  the  true  skin  and  oedema  of  the  con- 
nective tissue.  The  rete  Malpighii  is  infiltrated  with  cells,  the  stratum 
corneum  is  thickened  and  shows  hyperkeratosis. 

A  blood  examination  shows  a  reduction  of  the  red  cells. 

Fattv  degeneration  and  characteristic  deep  pigmentation  of  all 
viscera.  Wasting  of  all  muscles.  Intestinal  mucous  membrane 
hyperfemic,    sometimes   ulcerated.     Liver  and    spleen    atrophied. 

Brain  and  cord  show  chronic  leptomeningitis  with  much  thicken- 
ing, a  perivascular  cellular  infiltration  with  pigmentation  and  degenera- 
tion of  nerve  filaments.     Ventricles  distended.     Brain  shrunken. 

Lateral  columns  and  crossed  pyramidal  tracts  affected,  mid-dorsal 
region  most  marked.     The  condition  is  not  unlike  G.P.L 

SYMPTOMATOLOGY. 

Incubation  not  known,  but  the  disease  has  occurred  in  a  child  three 
months  old.     There  is  no  support  for  heredity. 

The  skin  eruption  has  occurred  in  a  healthy  person  two  months 
after  visiting  a  pellagrous  area. 

Onset,  insidious.  A  sunburn  may  appear  on  the  back  of  hands 
or  feet,  face  and  neck.  It  burns  and  may  blister.  Perhaps  sore 
mouth,  giddiness,  muscular  weakness.  In  a  few  weeks  the  redness 
fades  and  pigmentation  occurs;  the  skin  may  be  thickened.  In  a  few 
days  there  is  desquamation  of  these  areas,  the  underlying  skin  being- 
apparently  normal. 

Autumn  comes  and  the  patient  gets  better.  The  next  spring,  or 
several  seasons  later,  it  recurs  surely  and  more  severely ;  dermatitis  and 
bulk-E  may  appear;  inflammation  of  the  whole  mouth,  tongue  pro- 
truded with  difficulty,  edge  may  have  a  greyish  membrane,  there  is 
enlargement  of  the  parotid  gland,  dyspepsia,  abdominal  pains, 
diarrhoea,  or  even  dysentery.  Marked  vertigo,  the  patient  may  fall, 
weak,  trembling  in  head,  arms  and  legs,  melancholic,  highly  emotional^ 
patient  may  seek  to  drown  himself. 

He  has  burning  pains  at  night  and  may  go  to  the  river  to  relieve 
them.     Someone  pulls  him  out  of  the  water  and  reports  that  he  was 


334 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


seeking  to  drown  himself.  He  lias  abdominal  pains,  and  thinking 
that  the  cook  has  been  poisoning  him,  he  seeks  to  kill  the  cook  and 
finds  himself  in  an  asylum.     There  is  reason  in  his  madness. 

Winter  comes  and  with    it   relief,    but   the  skin   does   not   become 
normal.     With  repeated  attacks  the  skin  changes  are  marked,  the  mind 


Pellagra  in  Egypt.     Photograph  by  F.   M.  Sandwith,  M.D.,  M. R.C.I'. 


becomes  permanently  affected,  melancholic  or  maniacal  symptoms  set 
in.     Pain  about  the  back  at  either  side  of  the  dorsal  spine,  over  spinal 


nerves  in  dorsal  and  lumbar  regions. 


K.  J.'s  plus  later.  Patient  ^alks  with  his  legs  apart,  may  fall 
backwards  or  forwards 

Facies  of  anxiety  and  mental  worry,  sleeplessness,  discontent,  and 
mental  depression  or  excitement,  and  irritabilit}'  or  stupidity. 


PELLAGRA  335 

There  is  often  loss  of  memory.  He  may  refuse  food.  Dementia 
may  develop. 

There  may  be  ptosis,  hemianopsia,  diplopia,  amblyopia  and 
mydriasis. 

In  extreme  cases  the  bladder  is  paralysed,  there  is  profuse  diarrhoea, 
dropsy  and  death.     This  latter  in  five  to  fifteen  years  from  onset. 

Very  rarely  there  are  acute  cases  lasting  only  a  few  months. 

Skin  eruption  shows  congestion,  inflammation,  thickening  and 
pigmentation  of  a  light  sepia  tint.     Atrophic  wasting. 

The  tongue  sheds  its  epithelium  and  is  known  as  Sandwith's  bald 
tongue  (also  present  in  sprue  and  scurvy). 

Blood  pressure  is  low.  Pulse-rate  increased,  extremities  cold,  skin 
often  bluish. 

Sexual  power  is  diminished.     Saltish  taste  in  mouth  common. 

Temperature  but  little  altered.     Emaciation  marked. 

Complications  and  terminal  affections  are  naturally  numerous. 

To  sum  up  : — 

(i)  Cutaneous  signs  are  :  a  remitting  erythema  and  dermatitis  of 
the  exposed  parts.     The  skin  loses  its  elasticity. 

(2)  Gastro-intestinal  signs  are  :  salivation,  stomatitis,  oesophagitis, 
dyspepsia  due  to  hyperchlorhvdria,  nausea,  vomiting,  diarrhoea, 
dysentery  symptoms  and  constipation.  Proctitis  with  anal  excori- 
ations. 

(3)  INIental  symptoms  are  :  vertigo,  melancholia,  myasthenia,  trem- 
blings,  curious  delusions,   irritability. 

(4)  Genital  symptoms  are  :  intense  vaginitis,  a  sero-sanguineous 
discharge  with  excoriation  of  surrounding  parts.  Mucous  membrane 
a  scarlet  red  like  that  of  the  mouth. 

(5)  Nephritic  symptoms  are  :  acute  or  chronic  nephritis  in  many 
cases,  albumin,  and  casts  in  varying  proportions. 

DIAGNOSIS. 

From  acute  dermatitis  as  erythema  solare,  &c.,  by  the  gastro- 
intestinal and  nervous  symptoms. 

Fro'm  chronic  dermatitis  as  eczema  by  pigmentation,  peculiar 
localization  to  the  exposed  parts  chiefly. 

Ichthyosis  is  all  over  the  body  and  congenital. 

Gastro-intestinal  symptoms  as  sprue  by  their  not  having  an 
eruption. 

PROGNOSIS. 

Be  always  guarded.  Early  mild  cases  may  recover  if  removed  and 
placed  in  good  suitable  surroundings. 


336  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Cases  have  relapsed  after  two  to  fifteen  years. 

It  is  not  easy  to  say  when  a  person  is  free  from  the  disease,  once 
they  have  been  attacked  b}'  it.  It  is  better  to  speak  of  recovery  from 
an  attack  than  a  cure  of  the  disease. 

Recovery  is  more  frequent  and  more  permanent  in  children  than 
adults. 

The  death-rate  in  the  initial  attack  is  i5;8  per  cent.  (i,i8o  cases). 

The  death-rate  in  the  recurrent  attack  is  i2'3  per  cent.  (i,i8o  cases). 

It  is  higher  in  Black  than  White  races  (Siler,  Garrison  and 
MacNeal). 

Low  blood  pressure  may  cause  death  after  exertion. 

Typhoid  complications  have  a  high  mortality. 

Complications  such  as  ankylostomiasis  are  always  unfavourable. 

TREATMENT. 

There  is  none  specific. 

Protect  from  the  sunlight. 

Use  soothing  ointments. 

Diet  important,  fresh  fruit  and  fruit  juice,  meat  broths,  miik. 

Avoid  starchy  foods. 

Dilute  nitric  acid  15  to  30  minims  in  four  ounces  of  water,  thrice 
daily,  one  hour  before  meals. 

A  10  per  cent,  solution  of  trisodic  citrate,  intramuscular  or  sub- 
cutaneously. 

Atoxyl  3  grains  daily,  intramuscularly,  are  good. 

Liq.  arsenicalis  in  small  doses  can  be  tried. 

Radio-active  serum  injections  are  on  trial. 

Later  one  can  give  eggs,  meats,  fish,  green  vegetables  and  fresh 
fruit  with  dilute  nitric  acid  continuously. 

Remove  the  patient  to  a  non-pellagrous  area. 

The  Italian  Government  prohibits  the  sale  of  bad  maize. 

The  line  of  treatment  largely  depends  on  the  causative  view  held 
by  the  practitioner. 

BERIBERI. 
DEFINITION. 

An  acute  or  chronic,  endemic  or  sporadic  disease  of  unknown 
causation  ;  characterized  by  a  degeneration  of  peripheral  nerves  asso- 
ciated with  gastric  disturbances,  oedema  and  cardiac  failure. 

DISTRIBUTION. 

Eastern  Asia,  Japan,  China,  Philippines,  Indo-China,  Java,  and 
Malaya,    also  in    other   parts    frequently    where    Chinese    and    Indian 


BERIBERI  337 

coolies  are  imported.     It  has  been   reported   in   the  Congo  (Van   den 
Branden). 

It  is  the  scourge  of  many  mines  and  plantations  in  the  Malay  and 
Eastern  Archipelago. 

HISTORY. 

Beriberi  probabl}-  attacked  the   Roman   army   in   Arabia  (24  B.C.). 

In  the  Straits  Settlements  and  Malaya  (population  1,250,000)  there 
have  occurred  150,000  cases  with  30,000  deaths  in  the  Government 
Hospital  during  the  last  twenty  years  (Bradden). 

In  the  Japanese  navy,  prior  to  1884,  23  P^r  cent,  of  the  sailors  were 
continuously  disabled  by  it. 

In  the  Japanese  army,  during  1904  and  1905,  24  per  cent,  of  the 
total  sick  and  wounded  were  its  victims. 

The  Government  of  Malaya  pays  ^10,000  per  annum  for  direct 
hospital  cases. 

Labourers,  sailors,  soldiers  and  prisoners  are  most  frequently 
attacked. 

It  is  common  in  large  cities,  and  overcrowding  favours  its  spread. 

It  is  very  common  amongst  Mohammedans,  who  do  not  take 
alcohol. 

iETIOLOGY. 

It  is  a  deficiency  disease.  It  tends  to  be  racial  in  young  adults 
between  fifteen  and  thirty,  but  no  age  is  exempt. 

Disturbances  of  the  soil  and  high  atmospheric  pressure  are  pre- 
disposing factors.  The  exciting  cause  is  unknown,  but  theories  are 
legion.     The  chief  are  :  — 

(1)  Arsenical  Poisoning  (Ross,  1900).  It  is  based  largely  upon 
finding  arsenic  in  the  hair  of  recent  beriberi  patients.  Herzog 
failed  to  find  it  in  ten  patients. 

(2)  Oxalate  Poisoning  (Treutlein).  When  oxalates  were  given  in 
the  food  of  fowls  beriberi  symptoms  set  in.  The  acid  was 
supposed  to  remove  the  calcium  salts  and  so  predispose  to 
nerve  degeneration. 

Excess   of  calcium    salts  was   found    in    the   urine   of   beriberi 
patients. 

(3)  Carbon  Dioxide  Poisoning  (Ashmead).  The  result  of  excessive 
inhalation  of  carbon  dioxide.  Overcrowding  alone,  however, 
does  not  cause  it. 

22 


338 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


(4)   Food   Poisoning. 

Ichthyotoxismus  from  eating  bad  fisli,  but  those  not  eating 
fish  have  developed  it. 

Sitotoximus  due  to  eating  rice  without  the  husks  or  when  stale 
or  badly  kept.  Some  blame  a  parasite  living  in  the  husk  which 
is  ingested  when  the  rice  "is  insufficiently  cooked,  biit  it  has 
appeared  where  the  people  never  eat  rice. 


c  d 

a,  a  highly  milled  or  polished  rice  stained  by  Grams  iodine  solution.  The  starch,  being 
completely  exposed,  stains  uniformly  a  dark  blue.     This  rice  will  produce  beriberi. 

b,  an  undermilled  rice  stained  in  the  same  way.  The  unstained  areas  show  where  the 
adherent  pericarp  has  protected  the  starch  from  the  action  of  the  iodine.  This  rice  will 
probably  not  produce  beriberi. 

c,  a  sample  of  undermilled  rice  that  contains  still  more  pericarp.  The  use  of  this  rice 
will  surely  prevent  the  development  of  beriberi. 

d,  the  unhusked  grain  or  "palay."  When  the  husks  are  removed  by  hand  pounding, 
a  rice  like  c  or  /^  is  produced. 


(5)   Food  Deficiency.     This  is  the  view  held  most  widely. 

Deficient  nitrogen.     The  peripheral  layers  of  the  rice,  lost  in 
milling,  contain  a  vitamine  substance.     This  is  necessary  for 


BERIBERI 


339 


the  metabolism  of  nerve  tissue,   and   if  not   supplied   in   food, 
beriberi  appears  (Funk). 

Increase    in    the    food    of    nitrogen    for    Japanese    sailors    was 
followed  by  less  beriberi. 

Deficient  fat.     An  epidemic  at  Chaudabum  was  supposed  to  be 
stopped  by  an  increase  of  fat  in  the  food. 

Deficient  phosphorus.     Normal   rice  contains  0*4  per  cent,  of 
?  pentoxide.     If  less  it  is  a  dangerous  rice  (Fraser). 
Deficient    vegetables    with    an    infection.     The    disease    disap- 


Section  of  myocardium   from  case  of  beriberi,  showing  segmentation  and 

fragmentation. 

peared  when  a  sufficiency  of  vegetables,  chiefly  potatoes,  was 
given  (Fales). 

The  deficiency  causes  the  micro-organism  to  flourish  (Fales). 
Fletcher  concludes  that  uncured  rice  is  either  directly  or 
indirectly  a  cause  of  beriberi,  the  actual  cause  being  either:  — 

A  poison  contained  in  the  rice. 

Protein  deficiency. 

Bad    nutrition    resulting   from    uncured    rice   rendering   the 

patient  liable  to  invasion  by  the  specific  organism. 


22A 


340 


DISEASES  OF  UNCERTAIN  ETIOLOGY 

(6)   An  Intoxication  (Manson).     Caused  by  some  germ  living  out- 
side the  bodv,   in  the  soil,  house  or  ship  occupied  by  human 
beings  under  certain  conditions  of  temperature  and  moisture; 
the  toxin   inhaled  or  swallowed  causes  the  disease. 
Evidence.     Wiien  patients  are  removed  from  an  endemic  area 

they  begin  to  recover. 

The  germ  ma\-  be  carried  from  place  to  place. 

The  same  ship  redevelops  the  disease  annually  on  reaching 

the  Tropics. 


Section  of  myocardium  from  a  case  of  acute  wet  beriberi,  showing  more  advanced 
fragmentation.  (From  article  by  Herzog,  and  plate  lent  by  the  courtesy  of  TAe 
Philippine  [onrnal  of  Science.) 


(7)  An  Autointoxication  (Deurch). 

This  condition  is  asserted  to  be  produced  by  substances  formed 
in  the  body. 

(8)  Parasitic  Causes  (Sambon). 

The  parasite  in  some  way  enters  the  body. 

Insects  such  as  cockroaches  may  carry  it. 

The  infection  is  not  by  the  fceces  (Daniels),  nor  by  air  or  water. 


BERIBERI 


341 


Perhaps    an     intermediale    host,    such    as    lice,     is    necessary 
(Daniels). 

It  may  he  the  P.  capitis  as  such  have  a  tendency  to  clins"  to  one 

race. 

Amongst  the  suspected  parasites  are  :  — 

Various  protozoa,  nemathehninths,  bacilH,  fungi,  cocci,  and 
a  specific  bacillus  causing  duodenitis,  the  symptoms  of  this 
latter  arising  from  the  absorption  of  the  toxin  as  in  diph- 
theria (Hamilton  Wright).  Daniels  denies  duodenitis  and 
thinks  that  perhaps  a  protozoan  may  yet  be  found. 


Section  of  myocardium  from  a  case  of  sub-acute  wet  beriberi,  hsematoxylin-eosin  strain, 
showing  loss  of  striation,  vacuolation  and  granular  degeneration.  (From  article  by 
Herzog,  and  plate  lent  by  the  courtesy  of  The  Philippine  /ournal  of  Science.) 


PATHOLOGY. 

Blood  taken  from  a  beriberi  patient  and  injected  into  a  cat  produced 
a  fall  in  B.P.,  with  dilatation  of  the  gastric  vessels,  also  those  of  the 
intestines  and  liver.  The  right  heart  was  dilated  and  there  was  general 
venous  engorgement. 

P.M. 

There  is  always  some  oedema  in  acute  cases.  Often  froth  at  the 
mouth.     The  body  is  either  swollen  with  dropsy  or  emaciated. 


34'2 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


Longitudinal  section  of  jiopliteal  nevve  from  a  case  of  acute  beriberi.  VVeigerl-l'al  stain, 
showing  different  degrees  of  degeneration  of  the  medullary  sheath.  (P'rom  Ilcrzog,  plate  lent 
through  the  courtesy  of  7/ie  Philippine  Journal  of  Science.) 


Fibre  from  sciatic  nerve  of  fowl  suffering  from  polyneuritis  (Marchi  method),  showing 
advanced  degeneration.  (From  Vedder  and  Clark,  and  plate  lent  through  the  courtesy 
of  The  Philippine  potirnal  of  Science.) 


BERIBERI  343 

The  subcutaneous  tissues  are  usually  oedematous. 
The  veins  are  filled  with  dark  fluid  blood. 
There  is  serous  fluid  in  the  abdomen,  chest  and  pericardium. 
The  mucous  membrane  of  the  trachea  and  larynx  may  be  oedem- 
atous with  the  lumen  full  of  fluid. 

The  lungs  are  congested  and  oedematous. 
The  right  heart  is  dilated  and  fatty  degeneration  is  present. 
The  muscles  show  atrophied  and  normal  fibres  side  by  side. 
There  is  nerve  degeneration  of  the  bulbar  nuclei,  thoracic  ganglia, 
vagal  nerve  endings  and  peripheral  nerves. 

The  congested  liver  sometimes  shows  h^emorrhagic  patches. 
The  kidneys  show  cloudy  swelling  and  sometimes  hjemorrhages. 
Tile    meninges   are    hyper^emic   with   an    increase    of    fluid   in    the 
ventricles.     There  is  marked  degeneration  in  the  bulb. 
Thus  summing  up  one  finds  :  — 

Degeneration   of    nerves. 

Secondary  degeneration  of  muscles  including  the  heart.     Excess 

of  blood  in  the  right  heart  and  veins. 

Serous  effusions  into  the  cavities  and  cellular  tissue. 

Oedema  of  the   lungs. 

VARIETIES. 

Atrophic,  Dry  or  Paralytic. 

Hypertrophic,  Wet  or  Dropsical. 

Mixed. 

Infantile. 

The  incubation  is  unknown. 

(1)  The  Atrophic,  Dry  or  Paralytic  Variety. 

Insidious  onset,  malaise,  dull  pain  in  epigastrium,  tenderness 
on  pressure,  headache,  palpitation,  dyspnoea,  subcutaneous 
oedema,  K.  J.'s  slightly  increased,  sense  of  heaviness  in  the 
legs,  difficulty  in  walking,  K.  J.'s  disappear  gradually.  After 
the  first  week  there  is  usually  a  peculiar  high  stepping  gait, 
tender  calves,  "pins  and  needles,"  anaesthesia  and  paraes- 
thesia. 

The  anterior  tibial  and  peroneal  muscles  are  chiefly  affected. 
Sometimes  the  forearms  are  aft'ected  with  diminished  grip  and 
wrist  drop.  There  is  no  tremor  but  the  patient  is  often  too 
weak  to  hold  a  bowl  of  rice.  The  sphincters  are  normal. 
There  is  wasting  of  muscles,  the  paralysis  ascends  from  the 
calf  to  the  thigh,  gluteal  region,  arms,  abdomen,  diaphragm, 
intercostals  and  larynx. 
There  is  loss  of  sense  of  heat,  pain  and  cold,  but  the  areas  do 


344 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


Beriberi  :  oedematous  variety.    Japanese  immigrant  in  Fiji. 


Beriberi :  atrophic  variety,  showing  muscular  atrophy  and  drop-wrist.     Japanese  immigrant  in 
Fiji.     Photographs  by  Henry  Noble  Joynt,  Labosa,  P'iji. 


BERIBERI  345 

not  correspond  with  tlie  segmental  or  nerve  areas.  It  is  very 
patchy. 

Diffuse  apex  beat,  dilated  right  heart,  loud  systolic  murmur, 
reduplication  of  the  pulmonary  second  sound,  palpitation  and 
epigastric  pulsation. 

The  pulse  rate  is  increased  and  the  tension  diminished. 
With  increasing  oedema  the  urine  is  diminished,  when  the 
oedema  is  clearing  up  the  urine  is  increased.  Urea  and 
chlorides  are  diminished,  phosphates  and  indican  increased. 
There  is  cutaneous  oedema  ,of  the  legs,  scrotum,  abdominal 
wall,  face  and  arms,  with  exudation  into  the  abdominal  cavity, 
pleural  sacs  and  pericardium. 

Digestion  is  fair  but  a  good  meal  increases  the  epigastric  dis- 
tress.    The  bowels  are  often  constipated. 
The  temperature  is  normal  or  sub-normal. 
The  patient  may  remain  like  this  for  weeks  or  montiis,  some- 
times better,  sometimes  worse;  he  mav  recover  with  or  without 
paralytic  deformities  or  he  may  die  suddenly. 
If  fever  occurs  it  is  a  complication,  usually  T.  B.,  malaria  or 
dysentery. 

One  attack  predisposes   to   another.     The   patient  may   die   at 
any  time  during  the  attack. 
There  is  lymphocytosis  30  to  68  per  cent. 

(2)  The  Hypertrophic,  Wet  or  (Edematous  Variety. 

This  variety  is  usually  somewhat  acute. 

There  is  nausea,  epigastric  pain,  clean  tongue,  throat  con- 
gested, cardiac  oppression,  epigastric  pulsation,  palpitation, 
dyspnoea,  pulse  rate  much  increased  by  the  slightest  exertion, 
hcemic  murmurs,  right  heart  dilates,  urine  diminishes,  there  is 
effusion  in'o  the  cavities  of  the  pericardium,  pleural  and  peri- 
toneum. 

The  oedema  is  somewhat  localized  and  fugitive.  It  is  firmer 
than  in  Bright's  disease. 

There    are   patches    of    anaesthesia    and    In-perassthesia    in    the 
course  of  the  anterior  tibial  and  musculo-cutaneous  nerves. 
The  paralysis  may  be  slight  or  extensive. 

The  heart  becomes  more  embarrassed,  the  lungs  engorged,  the 
nostrils  dilate,  the  mouth  opens  in  the  struggle  for  breath,  the 
pupils  dilate,  the  face  becomes  cyanosed,  the  extremities  cold, 
the  patient  becomes  unconscious  and  dies.  This  may  take 
place  in  a  few  hours. 
Some  account    for   ihe   uxlema   b\-   suggesting   that    the   patho- 


346 


DISEASES  OF  UNCERTAIN  JF.TIOLOGY 


logical  condition  of  the  nerves  will  not  permit  of  the  regulation 
of  transudation  and  absorption  of  fluid  in  the  connective  tissues. 


Acute  wet  beriberi.      Great   oedema  of  legs  and  feet.     (From    Herzog ;    plate  lent 
through  the  courtesy  of   The  Philippine  [oiimal  of'  Science.) 

(3)  Mixed  Variety. 

There  is  oedema  over  the  shin,  feet,  flanks,  sternum,  and  the 
root   of   the    neck.     Some   hypera^sthesia,    paresis   and    ataxia. 


BERIBERI  347 

The  K.  J.'s  are  diminished.     Heart  as  before.     The   general 

heaUh    is    unaffected. 

Some  appear  almost  normal,  others  lie  like  logs. 

Some  appear  to  be  dying  one  day  and  seem  well  the  next. 

Some  are  like  skeletons  while  others  are  bloated  with  dropsy^ 

and  again  others  have  just  enough  dropsy  to  hide  the  muscular 

wasting. 

The  laryngeal  muscles  are  more  often  affected  so  that  coughing 

is  difficult.     A  profound  diuresis  converts  a  bloated  victim  into 

a  skeleton  in  one  day. 

(4)  Infantile  Variety. 

This    is   seen    in    the    Philippines   in    the    infants    of    beriberi 
mothers. 

They  have  a  defective  diet  and  suffer  from  oedema,  dyspepsia 
and  cyanosis.     They  often  die  suddenly. 

It  causes  56  per  cent,  of  the  infantile  mortality  in  the  Philip- 
pines 

P.M.  shows  degeneration  of  peripheral  nerves. 
Children  seem  to  improve  when  weaned,  suggesting  that  the 
cause  may  be  due  to  cessation  of  absorption  of  milk. 

DIAGNOSIS. 

Look  for  :  — 

Increase  followed  by  loss  of  K.  J.'s. 
Patches  of  anaesthesia   or  hypersesthesia   on   the   legs. 
Pain  on  handling  the  calf  muscles. 
Subcutaneous  oedema,  usually  of  the  leg  first. 
There  is  no  albumin  in  the  urine  and  no  fever. 
In    alcoholic    neuritis,    there    is    a    history    of    habit    and    general 
trembling. 

In  arsenical  neuritis,  there  is  abdominal  pain  and  diarrhoea. 
In  lead  neuritis,  there  is  colic  and  blue  line  on  the  gums. 
In  dropsies  due  to  heart  there  is  history  of  rheumatism  or  other 

fevers. 
,,  ,,         kidneys  there  is  albumin  in  the  urine  and  casts. 

,,         ankylostomiasis  there  are  ova   in  the  fasces. 
,,         epidemic    dropsy  there    is    fever   and    no   anass- 
thesia  or  paralysis. 
,,  ,,         mvelitis  one  finds  relaxation  of  sphincters. 

,,  ,,         pellagra    there    are    skin   eruptions  and    mental 

changes. 
Scurvy  should  be  excluded  by  the  spongy  and  bleeding  gums. 


348  DISEASES  OF  UNCERTAIN  ETIOLOGY 

In  diagnosing  the  condition  from  epidemic  dropsy  note  :  — 
(i)  The  Resemblances  and  (2)  The  Differences. 

(1)  The  Resemblances. 

There  are  epidemics   in  bolii   diseases. 
The  K.  J.'s  are  altered. 


Wet  beriberi.  General  .edema  below  ihe  waist.  Patient  shows  typical  facial 
expression  of  air  hunger.  Taken  on  admission  one  week  before  death  from  heart 
failure.     (By  JefTerys.) 

There  is  a  dropsical  condition. 
There  is  some  cardiac  disturbance. 
Some  disturbed  cutaneous  sensation. 
Some  hyperc-esthesia  in  both. 
Death  with  dyspnoea  or  orlhopnc^a. 


BERIBERI 


349 


(2)  The  Diflferences. 

Beriberi 

(i)  K.  J.'s  painful  for  24  hours,  then  dis- 
appear in  95  per  cent,  of  cases 

(2)  Anaesthesia  marked  and  not  limited 

to  dropsical  areas 

(3)  True  paralyses  even  when  no  swel- 

ling is  present 

(4)  HyperjEsthesia  is  found  in  muscles  on 

deep  pressure 

(5)  Death  is  more  sudden  and  more  dis- 

tressing,   often  in   cases  that  have 
not  been  obviously  bad 

(6)  There  is  no  antemia 

(7)  Ihitial  fever,  dry  skin,  rashes,  slight 

desquamation,  not  common 
8)  There  is  peripheral  neuritis  but  the 
central  nervous  systen)  is  not  affec- 
ted 


Epidemic  Dropsy 
K.  J.'s  seldom  if  ever  lost 

Anaesthesia  is  due  to  pressure  on  the  nerve 

terminals  about  the  dropsical  patches 
Paralysis  is  due  to  the  swelling  and  weight 

of  the  parts 
Hyperoesthesia  is  found    when  the  skin  is 

pinched  up 
Death    is  the  result  of  excessive  pressure 

and  the  impediment  of  essential  organs 

There  is  anaemia  and  ieucocytosis 

Initial   fever,  dry  skin,  rashes,  and    slight 

desquamation  common 
All   nerve   tissues   are   affected    somewhat 

equally 


PROGNOSIS. 

This  varies  considerably  and  is  according  to  the  country  and  the 
type  of  the  disease. 

In  Java  the  mortahty  is  2  to  6  per  cent. 

In  Sumatra  the  mortahty  is  60  to  70  per  cent. 

Cardiac  failure  is  always  bad.     To  move  much  is  fatal. 

Vomiting  is  a  bad  sign  as  it  indicates  that  the  vagus  is  involved. 

This  latter  feature  is  also  manifested  by  the  marked  dilatation  of 
the  stomach  and  embarrassment  of  the  heart. 

Death  may  be  due  to  dilatation  of  the  heart  and  syncope,  hydro- 
thorax,  pericardial  effusion  or  paralysis  of  the  diaphragm. 

The  dropsical  variety  is  more  serious  and  uncertain  than  the 
paralytic. 

TREATMENT. 

This  is  purely   symptomatic. 

Absolute  rest  in  bed  is  essential. 

Digitalis  or  strophanthus  is  good. 

Amyl  nitrite  or  trini  trini  should  be  handy. 

Venesection,  eight  ounces  to  relieve  the  right  heart  when  necessary. 

Oxygen  during  dyspnoea. 

For  paralyses,  strychnine,  massage  and  electricity  to  prevent 
atrophy  and  cramps. 

Removal  from  the  supposed  site  of  infection  as  soon  as  possible. 

Atropine,  one  150th  to  one  50th  grain,  hvpodermicallv,  or  tincture 
of  belladonna  for  dyspnoea  (Braddon). 

Plenty  of  good  nourishment,  in  small  quantities. 

Full  diet  plus  one  drachm  of  yeast  and  200  grm.  of  beans  daily 
(Simpson). 


350  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Yeast  can  be  obtained  as — 

Export  yeast,  of  which  give  2  ounces  daily. 

Royal  yeast  cakes  of  15  grm.  each,  give  six  daily. 

Fresh  yeast  from  local  bakeries,  250  c.c.  daily. 

Pour  into  the  yeast  some  boiling  milk,  stir  it  into  a  thin  cream, 

add  more  hot  milk  and  sugar  to  make  it  more  palatable. 
It  can  be  flavoured  with  essence  of  lemon. 
Foods  should  be  given,  as  the  patient  improves,  in  the  order  men- 
tioned,  viz.  :    Pea  soup,    eggs,    fresh   milk,   brain,    liver,    sweetbread, 
kidneys,  peas,  beans,  lentils,  porridge,  brown  bread,  meat,  and  fresh 
lemon-juice  the  whole  time. 

An  extract  of  the  outer  husk  of  rice  after  polishing  daily,  to  infants 
(Vedder),   in  twenty-drop  doses,   two  hourly. 
Eliminate  rice  from  the  diet  as  a  rule. 

Good  hygienic  surroundings  are  essential.  Little  water  is 
necessary. 

Disinfect  the  supposed  infected  house. 

EPIDEMIC  DROPSY. 
DEFINITION. 

A  specific  endemic  disease,  lasting  from  three  to  six  weeks  with 
fever,  profound  anaemia  and  the  sudden  appearance  of  anasarca. 

DISTRIBUTION. 

In  Calcutta,   Assam,   Daka,   Mauritius. 

It  disappears  as  the  hot  weather  comes. 

In  Mauritius,  one  tenth  of  the  population  was  attacked  with  a  mor- 
tality of  2  to  3  per  cent.     729  died  during  the  epidemic. 

In  Calcutta  the  attack  was  more  limited,  but  it  had  a  mortality  of 
20  to  40  per  cent. 

Europeans  in  these  localities  were  not  affected. 

^ETIOLOGY. 

Both  sexes  of  all  ages  are  equally  susceptible. 
The  disease  may  remain  latent,  breaking  out  later. 
It  is  not  very  contagious  if  at  all. 
How  it  is  transmitted  has  not  been  ascertained. 
The  causation  is  unknown. 

SYMPTOMS. 

In  Mauritius  the  epidemic  was  introduced  by  diarrhoea  and 
vomiting. 

There  is  itching  and  burning  of  the  soles  of  the  feet. 
Oedema  was  invariably  present,  the  legs  being  involved  first. 


HILL  DIARRHCEA  351 

It  may  affect  the  whole  body. 

Fever  to  102°  F.  is  usually  present  at  some  time  during  the  attack. 
Aching  of  muscles,  bones  and  joints  comes  on  early  as  a  rule. 

Anaesthesia  is  not  consistent  and  muscular  paresis  is  rare. 

An  eruption,  erythema  of  the  face  and  rubeola  of  the  trunk  and 
limbs  was  seen  in  Mauritius  but  less  so  in  Calcutta.  It  comes  seven 
days  after  the  oedema  appears  and  goes  in  ten  to  fourteen  days. 

Cardiac  dilatation  with  the  concomitant  symptoms  was  common  in 
Calcutta.  Pleural  and  pericardiac  effusions,  oedema  of  the  lungs  with 
their  corresponding  signs  and  symptoms  were  common  in  all  but  mild 
cases.     Anaemia,  wasting  and  prostration  was  marked. 

DIAGNOSIS. 

See  "  Differences  "   in  Beriberi,   p.  349. 

TREATMENT. 

This  is  symptomatic. 

Diuretics,  diaphoretics  and  saline  purges  to  remove  the  fluid. 

Tapping  may  be  necessary  to  relieve  the  lungs  or  the  heart. 

For  cardiac  weakness,  digitahs  or  strophanthus. 

For  attacks  of  orthopncea,   nitrites  and  trini  trini. 

Iron  and  arsenic  during  convalescence. 

HILL  DIARRHCEA. 
DEFINITION. 

A  gastro-intestinal  catarrh  occurring  in  high  altitudes  in  the  tropic  s, 
with  liquid,  pale,  frothy  morning  stools. 

It  is  somewhat  epidemic  in  the  Indian  Hill  Stations. 

AETIOLOGY. 

Causation  unknown. 

Perhaps  it  is  an  infection,  because  good  sanitation  and  good  water 
diminishes  its  frequency. 

THEORIES.     A  diminished  atmospheric  pressure  (Crombie). 
Irritation  by  mica  in  the  water  (Duncan). 
Fcccal  contamination  of  water. 
Exposure  to  cold. 

Functional  digestive  disturbance  in  the  low  temper- 
atures of  high  altitudes  (Bahr). 

PATHOLOGY. 

The  mucous  membrane  of  the  stomach  and  bowels  is  congesttJ, 
there  is  also  a  proliferation  of  lymphoid  and  fibrous  tissue. 
There  is  a  thick  layer  of  mucus  but  no  ulceration. 
The  tongue   is  seldom   affected. 


352  DISEASES  OF  UNCERTAIN  ETIOLOGY 

SYMPTOMS. 

It  begins  soon  after  arrival  on  the  hills  from  the  plains. 

The  onset  is  sudden  with  abdominal  pain  in  the  early  morning  and 
the  passage  of  stools  followed  by  relief.  This  is  repeated  next 
morning. 

The  stomach  feels  to  be  much  distended,  there  is  gurgling. 

The  patient  is  better  on  returning  to  the  plains.  In  Ceylon,  how- 
ever, there  are  similar  symptoms  with  patients  when  on  the  plains 
(Castellani). 

The  tongue  and  mouth  are  never  involved. 

It  has  a  very  low  mortality. 

TREATMENT. 

The  patient  must  avoid  hills  over  6,000  feet  high. 
Rest  in  bed.     Warm  clothing. 

Liquor  hydrarg.  perchlor.   i   to  i^  drachms,  fifteen  minutes  before 
each  meal.     Pepsin,   12  to  15  grains,  two  hours  after  meals. 
Milk  diet  diluted  as  necessary. 


SPRUE  (PSILOSIS). 
DEFINITION. 

It  is  a  chronic  catarrhal  inflammation  of  the  alimentary  canal ; 
characterized  by  large,  pale,  frothy  motions;  ulceration  of  the  tongue 
and  mouth   with   digestive   disturbances. 

DISTRIBUTION. 

Asia,  Burmah,  India,  China,  Japan,  Fiji;  West  Indies,  South 
America,  rarely  in  West  Africa  and  Europe.  Probably  world-wide  in 
tropical  and  sub-tropical  countries.  It  is  a  regional  as  opposed  to  a 
climatic  disease. 

ETIOLOGY. 

The  causation  is  unknown. 

Some  of  the  suggested  causes  are  :  climate,  food,  helminths, 
bacteria,  fungi,  protozoa  and  a  symptom-complex.  Fungi  are  often 
found  in  the  mouth  and  the  intestines  of  patients,  the  commonest  being 
the  genera  Monilia  and  Saccharomyces.  They  are  perhaps  secondary 
infections  causing  the  frothy  diarrhoea,  because  sodi-bicarb.  will  clear 
out  the  fungi,  when  the  frothy  stools  will  cease,  but  the  disease 
continues. 

Many  fungi  grow  badly  in  alkaline  media. 


SPRUE    iPSlLOSlS)  353 

Any  depressing  influence,  intestinal  irritation,  or  an  exhausting 
malady  will  predispose  to  the  disease.  It  is  generally  seen  in  old 
tropical  residents  during  or  after  being  in  the  tropics. 

It  may  be  a  specific  infection  falling  upon  over-stimulated  glands 
owing  to  certain  meteorological  conditions  (Manson). 

Intestinal  fermentative  changes,  bacterial  or  parasitic  in  origin,  may 
cause  it  in  those  long  resident  in  hot  climates  (Cantlie). 

It  is  a  disease  of  the  European  in  the  tropics. 

Natives  are  very  rarely  attacked. 

Both  sexes  of  all  ages  and  classes  are  subject  to  it. 

There  is  some  evidence  of  its  being  a  direct  infection. 

Inoculation  of  sprue  tongues,  scrapings  and  stools  injected  into 
animals  have  failed  (Bahr). 

Bahr,  a  recent  worker,  submits  evidence  of  its  being  a  blastomy- 
cotic  infection  which  may  be  summed  up  as  follows  :  — 

(i)  Yeast  cells  and  m}'celial  elements  are  found  intracellularly  in 
tongue  lesions  earlv,  but  not  later,  when  the  inflammation  has 
subsided. 

(2)  Yeasts  are  the  only  organisms  found  in  the  deep  layers  of  the 
tongue. 

(3)  The  desquamation  of  epithelial  cells  and  subacute  inflammation 
of  the  tongue  and  ciesophagus  are  changes  one  could  expect 
from  yeast  infection. 

(4)  Yeasts  were  found  in  intestinal  mucus  of  sprue,  but  not  in 
other  cases  of  chronic  diarrhoea. 

(5)  The  stools  are  such  as  one  would  expect  in  yeasts. 

(6)  Its  relapsing  nature  is  compatible  with  the  life-history  of  the 
Blastomyces. 

(7)  The  sprue  yeast  is  apparently  identical  with  the  thrush  fungus. 

(8)  Wasting,  anaemia,  and  degeneration  of  hepatic  capillaries  and 
endothelium,  the  symptoms  of  sprue,  are  reproduced  by  intra- 
venous injections  of  broth  cultures  of  a  pathological  veast  in 
animals. 

(9)  Similar  sprue  symptoms  are  found  in  infants,  the  subjects  of 
thrush  infections. 

(10)  The  scattered  portions  of  the  digestive  tract  affected  by  this 
fungus  would  best  explain  the  varying  clinical  manifestations 
of  sprue. 

(11)  The  local  tropical  conditions  favour  a  luxuriant  growth  of 
fungi. 

Dold  in  examining  sprue  stools  for  yeast  found  that — 
Normal  stools  yielded  yeasts  in  7*5  per  cent,  of  cases. 
Diarrhoea  stools  (not  sprue)  in  16  per  cent,  of  cases. 


354 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


Faeces  from  cases  of  sprue  in  92" i  per  cent,  of  cases. 

Either  Blastomycetes  or  Oidia  or  both  were  present  in  the  latter. 


Sprue.     "Small"  ulcer  of  intestine.      X  55. 

Dense  infiltration  of  submucosa  by  embryonic  cell  growth.     Invasion  of  villi  and 

crypts  of  Lieberklihn  with  subsequent  destruction  of  mucosa. 


Sprue.     Edge  of  "small"  ulcer.      X  55. 
Destruction  of  mucosa  by  infiltration,  and  subsequent  shedding  of  epithelial  structures. 


They  gave  acid  and  gas  reactions  on  all   kinds  of  sugars,   Avhich 
-explains  the  acid  reaction  and  the  gaseous  character  of  the  sprue  stool. 


SPRUE    (PS I LO SIS) 


355 


The  liver  is  diminished  in  size  due  to  carbohydrates  being  quickly 
decomposed  in  the  digestive  tract  by  tl;e  specific  orgrmisms  of  sprue, 


Sprue."    Base  of  small  ulcer  of  intestine.      X  55. 
The  mucosa  has  been  shed,  and  the  dense  infiltration  of  the  suhmucosa  is  causing  it  to  break 
down  and  come  away  as  a  necrotic  slough.     The  lymphatic  vessels  in  the  centre  of  the 

infiltrated  portion  are  full  of  pus. 


Sprue.     Base  of  small  ulcer  in  intestine.      X  350. 
Dense  infiltration  and  formation  of  pus  in  superficial  layers. 

leaving  little  or  none  to  be  absorbed   and  deposited   in   the   liver  as 
glycogen. 


356  DISEASES  OF  UNCERTAIN  ^ETIOLOGY 

But 

The  thrush  fungus,  Alonilia  albicans,  is  a  terminal  though  un- 
common infection  in  other  chronic  wasting  diseases  as  phthisis,  cancer, 
diabetes,  &c. 

Gastro-intestinal  infections  have  been  reported  in  the  temperate 
zone. 

PATHOLOGY. 

One  finds  desquamation  of  the  mucosas  of  the  gastro-intestinal  tract 
with  atrophic  changes  of  mucosa,  glands,  pancreas  and  liver. 

There  is  fatty  degeneration  of  the  tongue;  inclusive  elements  in  the 
epithelial  cells  is  a  well-known  feature.  There  may  be  large  structure- 
less cells,  keratohyalin  or  other  cells  containing  granular  agglomera- 
tions, cell  degenerations  or  inclusions. 

The  gastro-intestinal  tract  shows  submucous  congestion,  conges- 
tion, thrombosis,  exudation  of  haemoglobin,  round-celled  infiltration 
and  necrosis  of  the  mucosa.  Digestion  and  absorption  of  food  is 
hindered,  but  the  absorption  of  poisons  facilitated.  The  toxins  damage 
the  liver  and  a  toxaemia  results.  The  liver  is  congested  and  enlarged, 
or  more  often  atrophied  and  small,  the  result  of  hyper-activity  and  early 
exhaustion,  which  accounts  for  the  early  bilious  stools  and  later  the 
pale  frothy  motions. 

On  opening  the  intestines — 

The  upper  third  contains  normal  faeces  of  a  yellow  colour  due  to 
bilirubin. 

The  middle  third  contains  white  or  grey  faeces  due  to  alteration  of 
bile  pigments  into  chromogens. 

The  lower  third  contains  green  faeces  (Vaughan  Harlev). 

The  blood  picture  in  the  last  stages  of  severe  cases  may  resemble 
that  of  pernicious  anaemia.  Chromatin  granules  are  commonly  seen 
enclosed  in  red  cells. 

P.M. 

Body  emaciated,  wasting  of  all  organs,  absence  of  fat.  Skin  hangs 
in  loose  folds,  oedema  of  ankles.  Tongue  shows  patches  of  infiltration 
in  the  connective  tissue,  vesicles,  small  ulcers,  filiform  papilh-e 
atrophied  and  fungiform  papillae  swollen.  Pillars  of  fauces  and  tonsils 
show  sub-epithelial   inflammation,  suppuration  and  ulceration. 

(Esophagus  inflamed,   mucous  membrane  attenuated  in  patches. 

Stomach  :  mucous  membrane  pale,  atrophied,  rough  and  cirrhotic. 

Small  intestine  :  mucous  membrane  somewhat  eroded.  Large 
intestine  tilcerated. 

Peritoneum  thickened,  chronically  inflamed. 


SPRUE    {P  SILO  SIS)  y:,7 

Bowel  wall  ver}'  thin,  sometimes  like  tissue  paper.  Mucous  coat 
atrophied,  submucous  coat  has  fibrosed  areas  with  dirty  grey  tenacious 
mucus.  The  ^'illi  and  glands  destroyed.  Erosions  are  most  marked 
in  the  colon. 

In  the  swollen  endothelial  cells  of  the  venules  of  the  spleen  are 
certain  hvaline  bodies,  probably  of  a  degenerative  nature  not  found  in 
other  diseases,  perhaps  produced  in  response  to  the  extensive  yeast 
infection  found  in  sprue.  These  yeasts  are  small.  Gram-positive,  and 
have  no  affinit)'  for  fuchsin.     They  are  not  Russell's  bodies  (Balir). 

SYMPTOMATOLOGY. 

Insidious  onset.  Sore  mouth,  dyspepsia,  diarrhoea,  tongue  in- 
flamed but  clean  with  small  vesicles,  ulcers  and  bare  patches,  ditto 
on  palate,  pillars  of  fauces,  inside  of  cheeks,  acid  salivation. 

Warm  and  spiced  foods,  hot,  acid,  or  alcoholic  drinks  cause  pain. 

Mucus  accumulates  about  the  mouth.  Though  hungry  the  patient 
eats  little. 

There  is  a  burning  pain  behind  the  sternum  on  swallowing;  the 
neck  and  thorax  are  emaciated,  the  abdomen  is  distended  with  gas, 
and  the  ankles  with  oedema. 

There  is  discomfort  and  distension  after  meals,  acid  eructations, 
and  sometimes  vomiting. 

In  the  earl\-  morning  there  are  several  copious,  painless,  grey 
offensive,  frothy  stools. 

The  fasces  contain  mucus,  epithelial  debris,  many  bacteria  and 
fungi. 

The  nitrogen  and  fat  are  increased  (undigested  food  and  fatty  acids). 

Often  the  hydrochloric  acid  of  the  gastric  juice  is  diminished  or 
absent  (Manson).     The  same  applies  to  the  intestinal  digestive  juice. 

The  blood  coagulates  slowly.  There  is  anaemia,  1,000,000- 
2,000,000  reds. 

The  colour  index  is  low.     Leucopenia  to  3,000. 

Depression  and  irritability;  tongue  glazed,  small  and  fissured,  is 
more  like  cartilage. 

Pulse  slow  and  feeble.     Emaciation. 

An  acute  diarrhoea  or  cardiac  failure  may  cause  death. 

The  symptoms  are  often  intermittent,  but  steadilv  growing  from 
bad  to  worse.  The  disease  may  be  mild  or  virulent,  liable  to  sudden 
remissions  and  latent  periods. 

A   denuded   tongue   makes   mastication  difificult. 

,,  cesophagus  makes  swallowing  painful. 

,,  stomach  causes  dyspepsia, 

,,  intestine  causes  diarrhoea. 

23 


358  DISEASES  OF  UNCERTAIN  ETIOLOGY 

The  stools  are  pale  because  of — 
(i)  The  farinaceous  diet. 

(2)  A  colourless  reduction-product  of  hydrobilirubin. 

(3)  The  abnormal  percentage  of  cijnlained   fat. 
The  stools  are  large  owing  to 

(i)  The  lack  of  absorption  of  carbohydrates,  &c. 
(2)  The  lack  of  digestion  ,,  ,, 

The  acid  reaction  is  due  to  lactic  and  butyric  acids  (not  to  HCl), 
and  the  absence  of  pancreatic  ferments. 

Cammidge's  urinary  reaction  is  negative  (Bahr). 

DIAGNOSIS. 

An  irregularly,  chronic,  pale,  frothy,  morning  diarrhoea  with 
ulceration  of  the  mouth  and  flatulent  dyspepsia  in  a  tropical  resident 
is  in  all  probability  sprue. 

In  Stomatitis  the  characteristic  stools  of  sprue  are  not  present. 

In  Thrush,  look  for  the  fungi  Monilia  in  the  wliite  patches  of  the 
tongue.     This  condition,  however,   may  complicate  sprue. 

In  Hill  Diarrhoea  the  mouth  symptoms  are  i^ften  absent.  There  is 
a  history  of  living  at  an  high  altitude. 

In  Chronic  D3^sentery  the  mouth  symptoms  and  pale  stools  are 
absent,  while  blood  and  mucus  is  passed.  There  is  usually  no  griping 
with  sprue.     Look  for  amcebje  and  the  dysentery  bacillus. 

In  Chronic  Pancreatitis  the  mouth  is  normal,  there  is  much  fat  in 
the  stools,  and  there  are  Cammidge's  crystals  in  the  urine. 

Remember  that  the  denuded  epithelium  of  the  tongue  is  only  seen 
in  Sprue,  Pellagra  and  Scurvy. 

TREATMENT. 

The  patient  must  assist  the  practitioner.  His  co-operation  is 
essential. 

Absolute  rest  in  bed.  Avoid  chills.  Remove  all  sujDposed  causes. 
Clear  the  bowel  contents  with  castor  oil. 

The  diet  is  all-important. 

Milk  Diet. 

The  milk  must  be  free  from  contamination  and  adulteration. 

If  it  contains  much  fat  dilute  it  with  whey  made  ^itli  the  juice  of 
limes.     Sterilize  the  milk. 

If  the  attack  is  severe  begin  with  whey  onl}-,  ad  libitum,  7  to  8  pints 
daily. 

Milk,  sipped,  three  to  four  pints  daily  as  soon  as  possible. 

.A.S  the  symptoms  improve  increase  the  milk  gradually  bv  half  a 
pint  daily  until  seven  pints  are  being  taken.  Let  it  be  distributed  over 
tw^elve  meals  dailv. 


SPRUE    {P  SI  LOS  IS)  359 

For  six  weeks  there  should  be  no  other  food. 

The  patient  may  then  get  up. 

If  the  svmptoms  do  not  improve  reduce  the  amount  of  milk  and 
return  to  whey.     Starvation  diets  are  dangerous. 

Improvements  are  noted  bv  the  stools  becoming  brown  and  the 
mouth  troubles  diminishing. 

Should  the  milk  cause  vomitina^  add  sodi-bicarb.  or  sod.  citrate  or 
a  little  lime  water. 

Relieve  constipation  by  enemata. 

In  addition  to  the  milk  some  recommend  fruit,  such  as  strawberries, 
apples  or  bananas. 

Eggs  in  milk  can  then  be  given,  chicken  broth,  Benger's  food,  fish, 
biscuits  and  potatoes. 

Relapses  are  common.     Give  a  purge  at  once  and  begin  with  milk. 

Some  give  more  fruit  than  milk.  Fruit  which  is  not  acid  should 
be  given,  such  as  peaches,  pears  and  bananas. 

It  is  necessary  to  avoid : — 

Dark  meats,  most  vegetables,  spiced  foods,  cold  or  hot  drinks, 
all  indigestible  substances,  all  alcoholic  drinks  and  smoking. 

Meat  Diet. 

Six  ounces  of  raAv  meat  juice  with  a  little  dilute  h^'drochloric  acid 
and  salt. 

Give  one  teaspoonful  each  fifteen  minutes,  rapidly  increased  when 
possible.  Then  meat,  free  from  fat,  cartilage  or  fibrous  matter,  take 
2  lbs.  with  2  ounces  of  fresh  suet,  mince  and  pound,  cook,  and  give 
the  w^hole  in  six  separate  meals  daily. 

A  little  water  or  tea  with  lime  juice  instead  of  milk  should  be  taken 
twuce  daily  for  six  weeks.    '(The  Salisbury  cure.) 

In  seven  days  introduce  fruit,  chicken,  eggs  and  fish. 

Some  add  curdled  milk. 

Cantlie's  Treatment. 

Put  the  patient  to  bed.     Apply  hot  wet  packs  from  the  nipples 

to  the  groin  for  two  hours  morning  and  evening. 

A  binder  around  the  body. 

Three    meat    meals    daily    of    5   ounces   of   meat    with   beef-tea, 

calves'-foot  jelly  or  plain  jelly  and  salt  to  taste,  two-hourly. 

Castor  oil,  ivi  ounces,  each  morning  for  three  mornings. 

Santonin,  3  grains,  morning  and  evening. 

Strawberries,  3  lbs.  to  4  lbs.  daily  between  meals. 

When   the   stools   are   fairly   solid,    about   the  fourth   day,   add 

poached  c^g  and  minced  chicken.     "\^egetable  marrow  later,  and 


36o  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

thin  slices  of  bread  baked  in  an  oven  for  twenty  minutes. 
Give  milk  every  fourth  day  for  twenty-four  hours. 

Drugs. 

Astringents  are  dangerous,  antiseptics  useless. 

Yellow,  santonin,  3  to  5  grains,  twice  daily  in  olive  oil. 

If  the  santonin  is  white  expose  to  the  sun  for  a  few  days. 

Ipecacuanha,  20  grains  daily,  for  three  days  in  severe  cases 
(Cant  lie). 

To  be  discontinued  when  the  stools  are  brown  and  free  from  odour. 

Paint  the  mouth  with  glycerine  and  borax;  for  pain,  spray  or  paint 
on  2  to  5  per  cent,  cocaine  or  stovaine. 

Give  morphia  for  painful  oesophagus. 

Adrenalin,  5  to  10  minims  (i  in  1,000),  gives  immediate  relief. 

For  muscular  pain,  massage  and  pilocarpine,  i/ioth  gr.  to  i/5th  gr. 
thrice  daily. 

For  acute  diarrhoea^  opium  or  lead  and  opiimi  pills. 

Send  the  patient  to  a  temperate  zone  as  soon  as  possible. 

Alkalies  diminish,  acids  increase  the  symptoms. 

Cantlie  savs  that  milk  clots  in  the  acid  fermentation,  the  patient 
absorbing  only  the  whey. 

Emetine  and  streptococcal  vaccines  can  be  tried,  the  latter  prepared 
from  the  mouth  lesions  (Rogers). 

Good  results  have  been  obtained  with  the  following  medicinal 
remedies  :  — 

Large  doses  of  pancreaiin,  2  grm.  dail\-,  dilute  hydrochloric  acid, 
calcium  carbonate  and  a  liille  tannic  acid.  The  pancreatin  was  con- 
tinued for  months  with  good  effects  while  being  taken,  and  slight 
relapses  A\hen  it  was  omitted. 

Some  claim  good  results  from  Monilia  vaccines.  Six  injections 
of  ihe  emulsion,  eight  to  fourteen  days  apart,  the  primary  dose  of 
0*03  c.c.  increasing  to  a  final  dose  of  r40  c.c 

Of  62  patients  tluis  treated,  49  were  cured,  12  improved,  and  i  died 
(Michel). 

PHLEBOTO:\IUS  FEVER  (THREE-DAY  FEVER). 

DEFINITION. 

An  acute  specific  three-day  fever  of  unknown  causation,  spread  by 
the  Phlebotomus  papatasii. 

DISTRIBUTION. 

Around   the   Mediterranean   and    Adriatic   seas,   India,    Egvpt   and 
South  America. 
'    ■  It  agrees  with  the  distribution  of  the  P.  papatasii. 


PHLEBOrOMUS    FEl'ER    {THREE- DAY   FEVER)  361 

It  is  not  found  on  the  heights.  It  confines  itself  chiefly  to  inhabited 
places  (Doerr). 

It  is  a  disease  of  tlie  summer.  The  fly  dies  out  in  winter,  but 
perhaps  the  infection  is  continued  by  the  Qgg. 

iETIOLOGY. 

An  unknown  virus  is  infective  during  tlie  first  and  up  to  the  end 
of  the  second  day  of  the  fever  only. 

The  Pasteur-Chamberland  filter  keeps  back  the  virus. 

The  carrier,  P.  papatasii,  is  not  infective  until  one  week  after  it 
has  itself  become  infected,   hence  some  organism  develops  in  the  fly. 

The  infection  nia\'  be  transmissible  to  the  young  broods. 

An  antibody  is  probably  produced.  Serum  from  convalescent 
patients  may  neutralize  infected  serum. 

SYMPTOMS. 

Incubation  one  to  seven  davs. 

Sudden  onset,  as  a  rule,  like  most  fevers  with  chilliness,  severe 
frontal  headache,  pain  about  the  eyeballs,  general  body  pains,  injected 
conjunctivce. 

Skin  hot  and  dry,  temperature  rises  rapidly  to  104°  F.  in  twenty- 
four  hours,  pulse  100  to  116,  often  slow.  Ocular  movements  painful. 
Patient  irritable,  sleeplessness,  appetite  lost,  taste  impaired,  epigastric 
pain.  Diarrhoea  sometimes,  congested  mouth  and  throat.  Pain  in 
joints,  knee  and  elbow  especially.  Sensation  of  burning  in  the  palms 
and  soles.  Leucopenia  4,000  to  5,000.  Sometimes  a  general  ervthema. 
Temperature  falls  in  thirty-six  to  forty-eight  hours,  slowly  with  (often) 
epistaxis,  sweating,  vomiting,  diarrhoea  and  weakness. 

Convalescence  is  long.     No  death  has  been  recorded. 

Relapses  are  common.     Perhaps  there  are  no  reinfections. 

DIAGNOSIS. 

The  short  duration,  three  days,  is  about  the  only  diagnostic  feature. 

From  Influenza  by  there  being  no  catarrhal  symptoms  with  Three- 
day  fever. 

From  Dengue  by  the  short  duration  only. 

From  Malaria  by  there  being  no  parasites. 

From  Malta  fever  by  the  duration,  sudden  onset,  absence  of 
organisms  in  the  blood  and  negative  agglutination  test. 

TREATMENT. 

Rest  in  bed.     Saline  purges.     Aspirin.     Tonics  later. 
Prophylaxis  as  in  Malaria. 


362 


DISEASES  OF  UNCERTAIN  ETIOLOGY 

THE  PARASITE. 

Family  :    Psxchcjdidas. 
Sub-famih'  :   Phlebotominae. 


An  owl  midge,  P/ilebo/oiiius  sp.     Greatly  enlarged. 
(From  Giles's  "  Gnats  or  Mosquitoes." 

Genus  :   Phlebotomus. 
Species  :   P.  papatasii. 

Characters. 

Small  wings,  hairy,  second  long  vein  twice  forked.  Legs  long, 
slender,  densely  covered  with  scales.  Abdomen  of  ten  segments,  the 
last  carrying  the  genitalia.  The  oesophagus  divides  into  two,  one  to 
the  sucking  tube,  the  other  to  the  mid-gut. 

Life-History. 

The  female  after  fertilization  sucks  blood,  lays  30  to  80  eggs,  singly, 
in  damp  places  such  as  fissures  in  stones  and  bricks.  They  hatch  in 
four  to  six  days  in  warm,  twelve  to  fourteen  days  in  cold  weather. 

The  larvse  have  no  eyes,  well  developed  mouth  parts,  body  of  twelve 
segments,  spiracles  on  the  first  and  penultimate  segments. 

Two  very  long  bristles  on  two  tubercles  on  the  ultimate  segment. 

This  is  characteristic.  These  are  as  long  as  the  body.  Larval 
stage  lasts  two  to  fourteen  days.  Pup^e  motionless,  wrinkled  brown 
skin  on  the  last  three  segments  which  fixes  it  to  stones  in  dark  crevices. 

The  pupal  stage  lasts  eight  to  twenty-eight  days. 

The  whole  time  required  is  from  one  tO'  two  months. 

Habits. 

Nocturnal,  attracted  by  light.  During  the  day  it  is  found  in  shady 
places,  latrines,  under  stones,  &c.     The  female  only  bites. 

The  fly  passes  through  the  ordif.ary  mosquito  net. 

Spider  webs  are  useless  as  they  do  not  catch  them. 

The  bite  is  shar^'5,  it  leaves  a  rose  red  papule  set  in  a  reddish  macula. 
It  itches  for  days. 

Sunlight  drives  the  fly  away.     It  is  not  a  house-fly. 


J'ERRUGA    PERU  J 'I  AN  A  363 

VERRUGA  PERUVIANA. 
DEFINITION. 

It  is  a  clironic,  endemic,  non-contagious  disease  of  unk-no\vn  origin, 
resembling  raws.  It  is  characterized  by  irregular  fever,  associated 
with  rheumatoid  pains,  anaemia  and  granulomata  of  the  skin,  mucous 
membrane  and  viscera. 

HISTORY. 

It  was  in  South  America  before  the  Spaniards.  It  was  recorded 
there  in  1543. 

In  1885,  D.  A.  Carrion,  a  student  of  medicine  at  Lima,  desiring  to 
know  if  a  fever  then  present  was  related  to  verruga,  vaccinated  botli 
arms  with  the  blood  from  a  verruga  tumour.  In  twenty-one  days 
symptoms  set  in  and  he  died  of  the  fever  five  weeks  later.  Conse- 
quenth-  it  is  sometimes  known  as  Carrion's  fever. 

DISTRIBUTION. 

It  is  confined  to  certain  provinces  in  South  America.  Peru  is  the 
most  endemic  area.  It  is  prevalent  on  the  western  slopes  of  the  Andes 
and  Ecuador,  Bolivia,  and  the  northern  parts  of  Chili. 

It  is  found  in  narrow  valleys,  along  tributaries  of  rivers  and  small 
streams.  The  disease  only  occurs  in  summer  when  rivers  are  in  flood 
and  insects  abound.     Drinking-water  is  blamed  by  some  of  the  people. 

AETIOLOGY. 

The  causative  organism  is  unknown.  Perhaps  it  is  some  blood- 
sucking animal  that  carries  it  such  as  the  arachnoid. 

As  a  rule  one  attack  confers  immunity. 

Strangers  visiting  an  endemic  centre  are  very  prone  to  it. 

Xewly-born  infants  may  acquire  the  disease. 

In  some  respects  it  resembles  yaws,  but  unlike  that  disease,  it 
attacks  both  domestic  animals  and  man. 

PATHOLOGY. 

Some  doubt  the  identification  of  Carrion's  fever  with  nodular  fever. 

The  two  diseases  have  not  yet  been  proved  tO'  be  identical. 

The  disease  is  said  to  commonly  occur  among  animals,  &c.,  as 
horses,  mules,  asses,  dogs,  and  also  fow^ls. 

Post  mortem,  there  is  marked  pallor  of  the  bod\',  oedema  and 
dropsy,  hypostasis  of  the  lungs,  enlargement  of  the  liver  and  spleen, 
hyperasmia  of  the  bone  marrow.  Then  there  are  the  verrugas  of  the 
skin  and  other  parts  of  the  body. 

HISTOPATHOLOGY.     A  kind  of  neoplasm  begins  about  a  capillary 

vessel,  the  areolar  tissue  reacting  through  some  perivascular  irritant. 

The  connective  tissue  fibres  swell,  embracing  embryonic  connective 


364  DISEASES  OF  UNCERTAIN  ETIOLOGY 

tissue  cells.  The  interareolar  spaces  contain  polymorphs  and  macro- 
phages. A  non-ulcerative  skin  lesion  shows  the  cells  of  the  surface 
epithelium  swollen  and  distended  with  glycogen.  The  papillary  layer 
disappears,  the  dermis  is  infiltrated  with  round  cells,  there  are  numerous 
small  vessels  which  may  become  cavernous,  hence  the  possibility  of 
much  hemorrhage. 

The  subculaneous  fatty  tissue  is  ahva}"S  inflamed. 

Ulcerations  favour  secondary  infections. 

SYMPTOMATOLOGY. 

Incubation  is  unknown.     Perhaps  eight  to  forty  days. 

Prodromata,  malaise,  lassitude  and  depression.  Gradual  ancemia, 
rheumatoid  pains,  local  or  general,  sometimes  morning  fever  which 
may  rise  to  i04°F.,  insomnia,  and  sometimes  delirium.  Pulse  soft  and 
rapid.  The  fever  terminates  in  about  twelve  hours  with  sweating  and 
cessation  of  pains.     The  liver  and  Ivmphatic  glands  are  enlarged. 

There  is  constipation  as  a  rule  but  some  have  diarrhoea. 

There  is  a  great  destruction  of  red  cells  to  900,000  per  cm. 

The   HB    is   increased. 

There  is  always  a  marked  leucocytosis,  20,000.  The  polymorphs 
being  about  75  per  cent.  The  bone  marrcnv  shows  excess  of  normo- 
blasts and  neutrophile  myelocytes. 

SEVERE  TYPE  (Carrion's  Fever). 

The  fever  is  marked,  and  is  accompanied  by  severe  pains  and 
diarrhoea.  The  urine  is  acid,  dark,  scanty,  high  specific  gravity,  never 
blood,  rarely  albumin,  reduces  Fehling's  solution.  The  anaemia  is 
profound  to  500,000  in  extreme  cases  (Monge). 

Death  in  from  two  to  three  weeks, 

MILD  TYPE. 

The  febrile  stage  is  from  one  to  eight  months,  the  skin  itches,  the 
eruption  is  on  the  face,  neck,  arms,  legs,  conjunctiva,  about  and  within 
the  mouth.  Small  erythematous  spots,  sometimes  with  small  vesicles, 
rarely  with  bulU-e.  The  erythema  develops  into  a  papular  eruption 
about  the  size  of  split  peas.  These  are  discrete,  red,  firm,  small  warts, 
liable  to  bleed,  which  may  also  occur  on  the  mucous  membrane  and 
viscera.  vSome  larger  nodules  may  appear  to  be  free  under  the  skin, 
then  adhere,  ulcerate,  bleed,  then  becf)me  large,  red,  fungating  masses, 
chiefly  about   the  elbows   and   knees. 

There  may  not  be  any  health v  area  of  skin  left.  What  there  is 
becomes  oedematous,  ilie  fever  declines  with  the  presence  of  the 
eruption,  general  symptoms  abate,  the  patient  feels  better  but  the 
anjemia  is  marked  and  haemorrhage  from  the  nodules  may  cause  death. 


YELLOW    FEVER  365 

Wrrugas  occurring  in  the  larnyx  cause  dyspncea, 

bronchi  cause  bronchitis, 
lungs  cause  pneumonia, 
pleurae  cause  pleurisy, 
nose  cause  epistaxis  and  occlusion, 
oesophagus  cause  dysphagia, 
intestines  cause  blood  and  diarrhoea. 
,,  ,,  meninges   cause   cerebral    symptoms. 

,,  ,,  uterus  cause  metrorrhagia. 

In  four  to  six  months  there  are  several  crops  each  preceded  by 
attacks  of  fever.  The  eruption  then  disappears,  nodules  dry  up  without 
scarring,  ulcers  cicatrize.  The  patient  is  convalescent  but  anaemic  and 
weak.     The  eosinophiles  may  disappear. 

ATYPICAL  TYPE. 

Sometimes  the  eruption  is  less  typical  and  somewhat  localized  or  it 
ma\'  develop  and  disappear,  the  general  symptoms  returning  later  and 
are  then  more  serious. 

Some  cases  show  but  little  fever. 

PROGNOSIS. 

An  early  general  eruption  is  a  good  sign. 
A  mild  eruption  with  ana?mia  is  bad. 
Subcutaneous  nodules  with  Carrion's  fever,  bad. 
JNIortalitv   10  to  40  per  cent. 

The  disappearance  of  a  poor  eruption  with  a  return  of  the  fever  and 
the  pains  are  bad. 

TREATMENT. 

There   is   nothing  specific   known. 

Remove  the  patient  from  the  endemic  area  to  warm  country  districts. 

Try  arsenic,  atoxyl,  arsenobillon. 

Avoid  chills  and  cold  baths. 

Drugs  are  useless  in  the  febrile  stage. 

Give  tonics  during  the  convalescence. 

Treat  Carrion's  fever  as  typhoid. 

YELLOW   FEVER. 
DEFINITION. 

It  is  an  acute  specific,  endemic  and  epidemic  fever,  characterized  by 
two  paroxysms  of  fever  separated  by  an  intermission;  albuminuria, 
jaundice,  black  vomit  and  haemorrhage. 

The  Stegomyia  calopus  carries  the  virus. 

DISTRIBUTION. 

Yellow  fever  is  supposed  to  have  attacked  the  troops  of  Columbus 


366  DISEASES  OF  UNCERTAIN  ETIOLOGY 

in  1495,  in  ihe  island  of  St.  Domingo.     These  Spanish  troops  carried 
it  to  America. 

It  is  endemic  un  ihe  east  coast  of  Mexico,  Central  and  South  America 
as  far  as  Rio  de  Janeiro,  and  the  Antilles.  Also  in  Guatemala,  Spanish 
Honduras,  Nicaragua,  Costa  Rica,  Labrador,  French  Guiana,  Dutch 
Guiana,  Ecuador  and  along  the  rivers  Magdalena,  Orinoco  and 
Amazon. 

The  true  home  centre  is  Central  America  and  the  West  Indies. 

It  was  formerly  common  but  now  is  extinct  on  the  Isthmus  of 
Panama. 

Since  1905,  eleven  cases  have  been,  d^ected  and  isolated  by  the 
Canal  Zone  authorities. 

These  cases  came  from  Cartagena,  Guayacjuil  and   Buenaventura. 

The  epidemic  of  1635  to  1690  affected  Guadeloupe,  Cuba,  Jamaica, 
San  Domingo,  Martinique  and  Vera  Cruz. 

West  Africa  has  probably  been  a  second  endemic  centre  since  1520, 
when  the  Cape  \>rd  Islands  and  the  Gulf  of  Benin  had  an  epidemic. 

From  these  endemic  centres  ships  carr}-  the  disease  to  46°  56'  X., 
and  34°  54'  S.  Towards  the  North  the  disease  becomes  milder  but 
towards  the  South  it  may  become  very  severe. 

England,  Swansea,  was  attacked  in  1S65  but  it  died  out. 

France  was  attacked  in   1861. 

Madrid  in  Spain,   in   1878. 

The  distribution  seems  to  coincide  with  that  of  the  mosquito,  S. 
calopus. 

This  is  supported  by  the  fact  that  :  — 

The  disease  is  endemic  in  warm  climates. 

It  increases  in  the  summer  and  disappears  during  the  winter  in 

temperate  climates. 

It  is  carried  by  ships. 

It  affects  low-lving  parts  of  the  coast,  especially  (he  insanitary 

districts. 

An  atmospheric  temperature  of  over  75°  F.  is  required  for  its  active 
propagation.  Towns  upon  the  sea  coast,  banks  of  rivers  and  near 
deltas  are  often  infected. 

The  disease  follows  lines  of  communication. 

In  Rio  de  Janeiro  visitors  maintain  the  disease. 

Long  residents  in  an  infected  district  tend  to  become  immune. 

AETIOLOGY. 

The  causative  organism  is  an  ultra-microscopic,  non-filtrable  virus, 
because  :  — 

o'l   c.c.  of  infected  blood  will  reproduce  the  disease  in  a  non- 
immune person. 


YELLOW    FEFER  367 

Diluted  blood  passed  through  a  Fasteur-Chambeiiand  filter  will 
cause  the  disease  when  injected  intravenously  into  a  non-immune. 
Time  is  recjuired  for  the  virus  to  develop  in  man  and  the  mosquito 
before  it  is  infective,  three  days  in  man  and  twelve  days  in  the 
moscj[uito,  hence  it  cannot  be  a  chemical  substance. 
If  infected  serum  is  diluted  the  virus  becomes  more  and  not  less 
potent  after  time  has  been  allo^ved  for  growth. 
The  virulence  of  the  blood  is  destroyed  at  55°  C. 
The  S.  calopus  is  absolutely  necessary  for  its  spread. 
Contact  with   the  bedding,    fomites  and   excretions  of   an    infected 
person  will   not  cause  it.     The  virus  may  only  live  in  man  and  the 
S.  calopus. 

The  higher  apes,  guinea-pigs  and  fowls  are  suspected. 
The  fly  must  go  twelve  days  after  feeding  upon  an  infected  patient 
before  its  bite  will  reproduce  the  disease  in  man,  but  these  flies  are  then 
infective  for  life. 

According  to  French  physicians  the  virus  can  be  transmitted  by 
the  mosquito  to  the  first  and  second  generations.  These  cannot  infect 
man  until  they  have  been  adult  flies  for  thirteen  days. 

The  adult  mosquito  can  live  for  about  five  months  and  la}s  seven 
batches  of  eggs.  The  fly,  before  her  first  egg-laving,  is  immature  and 
bites  at  any  time  but  is  harmless.     Afterw^ards  she  is  strictly  nocturnal. 

PATHOLOGY. 

The  Liver. — The  liver  cells  swell,  pressing  upon  the  bile  capil- 
laries obstructing  the  bile,  causing  hepatogenous  jaundice,  staining 
the  skin  and  tissues  yellow  and  passing  out  in  the  urine. 

The  swollen  liver  cells  also  block  the  intralobular  capillaries  causing 
congestion  of  all  viscera  drained  by  the  portal  vein,  especially  the 
pyloric  region  and  the  duodenum.  This  impaired  circulation  predis- 
poses to  secondary  infection. 

Portions  of  liver  are  so  degenerate  that  the  urea  function  is  impaired 
and  a  universal  toxic  condition  due  to  the  resulting  ammonic-emia  sets 
in.  Haemorrhages  are  caused  as  a  result  of  the  damaged  epithelial 
lining  of  the  capillaries. 

The  Blood. — A  few  normoblasts  may  be  present,  otherwise  the 
number  and  shape  of  the  red  cells  are  normal.  The  loss  of  hb.  is 
marked  after  the  third  or  fourth  dav.  The  specific  gravity  of  the  blood 
falls,  its  coagulation  is  diminished. 

Hasmoglobin^emia  often  occurs  before  death. 

Ammoniaemia  is  present  in  bad  cases. 

The  polymorphs  are  slightly  increased,  3,200  to  20,000  per  cm. 

The   Urine. — Albumin  on  the  second  day  which  increases  rapidly. 


368  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Bile  appears  about  tlie  fifth  or  sixth  day.  Red  cells  may  be  present, 
leucocytes  are  rare.  Casts,  h\a!ine,  i^ranular  and  epithelial  appear  in 
turn. 

I'rea  is  diminished  in  bad  cases. 

The  diazo  reaction  is  usually  absent. 

The  Yomit.  P^irst  white,  consisting  of  mucus;  acid  and  colourless, 
or  it   may  be  blood-stained. 

Then  red,  consisting  cliiefly  of  bright,   red  blood. 

Later  black,  consisting  of  red  cells,  debris,  fat,  epithelial  cells, 
micro-organisms  and  hydrochloric  acid  in  traces.  The  IICI  converts 
the  hb.  into  acid  hcLMiiatin  giving  the  black  cohjur. 

The  Immunity. 

Racial  immunity,  so-called,  in  endemic  regions  is  really  due  to 
their  having  had  mild  attacks  in  childhood. 

Acquired  immunity  usually  is  lifelong,  and  is  given  by  a  typical 
attack. 

Relative  immunity  is  acquired  by  receiving  an  inoculation  of 
infected  blood  serum,  heated  for  five  minutes  to  55°C. 

It  has  been  shown  conclusivelv  that  negroes  of  the  West  Coast  are 
not  immune  to  yellow  fever  but  are  as  liable  as  whites, 

BUT 
the  practitioners  of  Guayac|uil  recognize  the  natural  immunity  of  very 
young  children  and  have  presented  evidence  in  support  of  their  views 
(O'Brien).     This  appears  to  pass  off  with  age,  during  which  transient 
periodic  mild  attacks  give  an  acquired  immunity. 

P.  M. 

The  skin  is  yellow  and  stained  with  hccmorrhages. 

The  buccal  mucosas  is  fissured,  the  mouth  may  contain  blood. 

The  liver  is  yellowish  brown,  h^emorrhagic,  cells  swollen  and  fatty. 

The  gall-bladder  contains  inspissated  bile,  perhaps  mixed  with 
blood. 

The  spleen  is  congested  and  soft,  normal  in  size. 

The  gastro-intestinal  tract  is  full  of  black  tarry  blood. 

The  mesenteric  glands  are  sometimes  enlarged. 

The  kidneys  are  congested,   not  enlarged. 

The  urinary  tubules  show  fatty  degeneration  with  granular  debris 
in  the  urine. 

The  urinary  bladder  is  usuallv  empty. 

The  pericardium  may  show  effusions  and  the  heart  ecchymoses. 

The  pleurae  may  show  haemorrhages;  the  lungs  are  often  congested. 

The  uterine  mucosa?  are  congested  and  the  organ  mav  contain 
blood. 

The  meninges  are  congested  and  may  show  hcemorrhagic  spots 


VELLOJV    FEJ^ER 


369 


SYMPTOMATOLOGY. 

Incuhiitiou . — Two  to  seven  days. 

Prodrnniiitit  usualU'  absent.  JMalaise  may  be  present  for  several 
days. 

The  First  Fever. — This  comes  on  the  first  or  second  day,  severe 
frontal  headache,  sometimes  rigors,  pain  in  back  and  Hmbs,  face  and 
skin  flushed,  eyes  injected  and  painful,  temperature  rises  rapidly  to 
103°  F.  or  higher,  respirations  quick  and  laboured,  pulse  increases 
from  100  to  120,  full  and  bounding.  \"omiting  with  epigastric  pain, 
constipation,  urine  diminished  with  high  specific  gravit_y,  acid  re- 
action, albuminuria  on  second  day,   insomnia. 


TIME 

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r  ° 

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1  04 
1  03 

ro2 

1  0  1 

1  00 

S3 

98 

A 

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J 

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y 

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Yellow  fever.     Severe  attack. 


The  Crisis. — This  occurs  about  the  end  of  the  second  day.  The 
temperature  falls  suddenly  to  normal  or  subnormal  with  sweating,  the 
pain  and  the  flush  both  disappear,  the  patient  feels  better  and  sleeps 
well.  The  urine  increases.  A  mild  abortive  case  mav  recover  at 
this  stage. 

The  Second  Fever. — This  occurs  on  the  second  to  the  fourth  dav. 
A  few  hours  after  the  temperature  has  fallen  to  its  lowest  and  the  crisis 
has  taken  place  the  temperature  begins  to  rise  again  steadily  until  it 
reaches  104°  or  105°  F.  But  the  pulse  decreases  to  sixty  or  fortv  beats 
per  minute  (Faget's  sign).  The  skin  becomes  jaundiced,  and  it 
deepens  with  the  days.  The  vomiting  and  the  epigastric  pains  return 
with  thirst  and  prostration.  Tongue  dry,  furred  with  red  tip  and 
edges.  Haemorrhages  everywhere,  vomit  black,  mal^ena,  epistaxis,. 
subcutaneously,  from  the  mouth,  &c.  The  urine  diminishes,  albumin 
increases.  There  may  be  anuria.  Restlessness  and  delirium  are  often 
present. 

The  Termination. —  If  recovery,  then,  after  about  four  days,  the 
temperature  declines,  sweating  commences,  more  urine  is  passed, 
albumin  diminishes,  vomiting  ceases,  sleep  is  usual,  and  convalescence 
sets  in. 


370  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Recovery  is  rapid. 

If  fatal,  then  jaundice  deepens,  bleeding  becomes  worse,  urine  is 
suppressed,  subsultus  tendinum  is  seen,  coma  and  convulsions  precede 
the  fatal  issue.  Death  may  ensue  in  an  acute  attack,  preceded  by  a 
rapid  rise  of  temperature. 

Relapses  may  occur  at  any  time  within  two  or  three  weeks  of  the 
attack,  and  are  predisposed  to  by  dietetic  errors. 

PROGNOSIS. 

As  a  rule  convalescence,  when  it  has  set  in,  is  not  protracted  or  com- 
plicated.    Pre-existing  heart  or  kidney  affections  are  bad. 

Congestion  of  the  lungs,  abscesses,  gangrene  and  intussusception 
are  dangerous  complications. 

Dvsentery  and  hepatitis  are  common  sequelae  and  add  to  the  gravity 
of  the  case. 

In  the  United  States  the  mortality  is  lo  to  25  per  cent. 

In  West  Africa  and  the  endemic  area  the  mortality  is  45  to  80  per 
£ent. 

In  children  ihe  mortality  is  low. 

Anuria,   hvperpyrexia,   black  vomit,  malsena  are  all  bad  omens. 

All  cases  are  serious,  especially  for  alcoholics. 

Abortion  is  the  rule. 

DIAGNOSIS. 

Early  cases  are  always  difificult. 

Typical  attacks  are  easy. 

Mild  attacks  in  a  non-endemic  area  are  difficult. 

It  is  all-important  to  diagnose  early. 

Look  for  albuminuria,  Faget's  sign,  jaundice,  and  the  black  vomit. 

Dengue  shows  a  preliminary  rash,  leukemia,  no  albuminuria,  and 
"Faget's  sign  is  absent. 

Subtertian  malaria  shows  the  blood  plasmodium  and  absence  of 
Faget's  sign. 

Blackwater  fever  shows  a  mononuclear  increase  with  destro^'ed  hb. 
rin  the  urine. 

Relapsing  fever  shows  blood  parasites  and  a  leucocvtosis. 

TREATMENT. 

The  indications  are  :  — 

(i)  To  prevent  the  spread  of  the  infection. 

(2)  To  eliminate  the  toxins  rapidly. 

(3)  To  alleviate  the  symptoms. 

We  will  deal  with  preventive  measures  last. 


YELLOW    FErER  371 

To  eliminate  the  Toxins  rapidly. 

By  the  BoivcL — Give  small  doses  of  calomel  to  disinfect  the  alimen- 
tary tract.  Follow  this  with  doses  of  sodium  sulphate  until  the  bowels 
are  well  opened.  Afterwards  give  enemata,  twice  daily,  of  sodium 
sulphate,   ij  drachms  to  i  pint. 

By  the  Skin. — Wrap  the  patient  in  warm  blankets,  but  not  so  as 
to  oppress  the  patient  with  them.  Precede  this  by  a  hot  mustard  bath. 
By  these  measures  the  skin  will  be  stimulated  and  the  headache  relieved. 

By  the  Kidneys. — To  stimulate  the  kidneys  and  dilute  the  toxins 
use  Sternberg's  treatment  :  — 

I^     Sodii  bicarbonatis  ...  ...         ...         ...     grains  150 

Hydrargyri  perchlor.  ...  ...  ...         ,,  J 

Aquas  ...         ...         ad     60  ounces 

Give  li  ounces  hourly 

or,  a  drink  of  sodium  bircarbonate  and  fresh  limejuice  n-,ade  neutral  with  sodium 

sulpliate  if  necessary.     This  may  be  administered  per  rectum. 

To  alleviate  the  Symptoms. 

Relieve  pain  by  aspirin  or  phenacetin,  never  opium. 

Apply  hot  fomentations  for  severe  lumbar  pain. 

Warm  mustard  bath  for  increasing  the  urine. 

Do  not  give  food  during  the  first  few  days. 

Prevent  vomiting  by  sips  of  champagne,  iced  if  possible. 

Put  plasters  to  pit  of  stomach. 

Treat  hyperpyrexia  by  cold  sponging. 

Bleeding  should  be  treated  b}'  calcium  lactate  or  adrenalin  injection 
or  ergotin. 

Anuria  by  hot  fomentations  to  the  loins,  cupping,  hot-air  baths. 

Cardiac  insufficiency  by  strychnine,  camphor,  or  ether. 

Weakness  should  be  met,  after  three  days,  w^ith  milk,  lime  water, 
toast  water,  cream,  lemon  jelly,  olive  oil  bv  mouth  or  skin. 

After  three  days  of  normal  temperature,  chicken  broth,  custards,  &c. 

Avoid  strong  alcoholic  stimulants  and  meat  extracts. 

Be  very  careful  during  remissions  not  to  give  food. 

Always  increase  diet  with  great  caution. 

PROPHYLACTIC  MEASURES. 

To  spread  the  disease   three   factors  are   necessary  :  — 

An  infected  person  from  the  first  to  the  third  dav  of  the  disease. 

The  presence  of  non-immune  persons. 

The  presence  of  the  Stegomyia  calopus  (fasciata). 

To  spread  the  infection  the  fly  must  bite  the  patient  infected  during 

the   first  three  days.     Twelve  days  must  elapse   for  the  development 

of  the  virus  in  the  mosquito;  then  it  can  bite  and  infect  a  non-immune 


2,72  DISEASES  OE  UNCERTAIN  .ETIOLOGY 

person  for  the  rest  of  its  days,  and  may  also  hand  down  the  virus  to 
the  first  and  second  generation,  these  latter  spreading  the  disease 
fourteen  days  after  becoming  adults. 

An  infected  ship  should  be  ancliored  a  quarter  of  a  mile  from  the 
shore  or  other  ships  as  the  fly  is  not  likely  to  cross  this  distance. 

The  quarantine  should  be  five  to  seven  days  because  the  incubation 
is  up  to  seven  days. 

Place  the  sick  in  mosquito-proof  rooms,  mesh  twenty  strands  to. 
one  inch,  and  tjuarantine  the  remainder  of  the  crew  or  members  of  the 
household. 

Disinfect  the  ship  by  a  Clayton's  disinfector. 

A.S  the  flies  are  cjuiet  between  9  a.m.  and  3  p.m.  visits  can  then  be 
made  without  risk. 

Houses  should  be  fumigated  by  sulphur  dioxide  or  pyrethrum 
powder,  burnt  in  the  proportion  of  2  lbs.  to  1,000  cubic  feet  of  space. 

The  breeding  places  of  the  flies  should  be  destroyed. 

BOYCE'S  SUMMARY. 

(A)  When  the  fever  is  endemic  :  — 
(i)  Segregation  of  non-immunes. 

(2)  Screening    of   bed,    verandah,    or,    if    possible,    the    house- 
completely. 

(3)  Systematic  mosquito  destruction  by  :  — 

Removal  of  breeding  places. 

Screening  of  water  cisterns. 

Oiling  of  waters  not  screened  or  drained. 

The    infliction    of    fines  for    non-observance   of   sanitary 

rules. 

Drainage  and  bush  cleaning. 

(4)  Education. 

(5)  Quarantine  administration. 

(B)  When  vellow  fever  has  already  broken  out  :  — 

(i)  Removal     of    non-immunes    from    the    infected    area    and 
deflection  of  the  trafific  from  this  area. 

(2)  Isolation  of  all  cases,  sure  and  suspected. 

(3)  Provision  for  isolation  of  contacts. 

(4)  Early  notification. 

(5)  Fumigation. 

(6)  Emergency  mosquito  measures  :  — 

Removal  of  receptacles,  oiling,  screening,  and  draining- 

(7)  Education  by  lectures,  meetings  and  pamphlets. 

(8)  General  organization  of  the  medical  forces. 


NOTES    ON   THE    YELLOW   FEVER   MOSQUITO         373 

NOTES  ON  THE   YELLOW  FEVER   MOSQUITO, 
STEGOMYL^  CALOPUS  (FASCL'VTA). 

(oreyo"?  =  a  house;    jjLvia       a   fly.) 
The    S.    calopus    belongs    to    the    CuHcales    of    the    sub-family, 
CuHcinse. 

On  account  of  its  wide  distribution,  domestic  habits,  vital  tenacity 
of  its  eggs,  the  different  infections  it  is  capable  of  carrying,  yellow 
fever  in  particular,  it  is  one  of  the  most  formidable  insects  in  existence. 
They  are  small  black  mosquitoes,  with  bright  whitish  markings  on 
head  or  thorax,  and  bright  w^hitish  transverse  marks  on  abdomen  and 
legs.  They  are  common  in  all  tropical  and  sub-tropical  climates 
between  40°  N.  and  40°  S.  from  sea-level  to  nearly  3,000  feet  high. 

THE  ADULT  FEMALE. 

The  head  is  black  with  white  markings  not  unlike  a  crown  in  shape; 
the  palpi  are  short,  black,  tipped  with  white.  The  scutum  is  brown, 
with  a  lyre-shaped  set  of  marks  thereon.  The  scutellum  is  white.  The 
abdomen  is  blackish  brown,  with  white  transverse  bands  across  the 
dorsum  and  on  the  sides  of  the  segments.  The  femora  are  black  with 
a  white  tip;  the  tibia  black,  the  tarsus  black  with  two  to  five  white 
bands.  It  has  the  common  mosc|uito  wing,  with  the  third  and  fifth 
long  vein  forked. 

The  adult  male  is  similar,  but  has  long  palpi,  and  does  not  bite  man. 

HABITS. 

A  house-haunting  mosquito  always. 
Perhaps  the  commonest  mosquito  on  board  ship. 
It  bites  in  the  daytime  as  well  as  at  night. 
It  breeds  close  to  human  habitations. 

Its  eggs  are  laid  in  anything  that  holds  water — a  sardine  tin  or 
water-barrel. 

EGGS. 

Almost  black,  laid  in  seven  batches,  they  stick  closely  together, 
but  not  in  rafts.  They  are  very  resistant;  if  kept  dry  they  will  remain 
fertile  for  six  months. 

The  yellow-fever  virus  is  transmitted  to  a  second  generation. 

LARY^E. 

Dark  in  colour,  has  a  short,  stout  breathing  tube  and  very  large 
tracheal  gills.  Laterally,  on  the  eighth  abdominal  segment  is  a  single 
row  of  eight  to  nine  scales  like  miniature  arrow  heads  and  a  wisp  of 
three  small  hairs.  It  can  remain  submerged  for  a  long  time,  and  can 
live  in  filthy  water  aided  by  its  large  tracheal  gills. 

24 


374  DISEASES  OF  UNCERTAIN  ETIOLOGY 

SPOTTED  FEVER  OF  THE  ROCKY  MOUNTAINS. 
DEFINITION. 

An  acute  endemic,  non-contagious,  febrile  disorder,  with  a  petechial 
or  papuric  eruption  following  the  bites  of  infected  ticks.  It  is  found 
in  valleys,  in  siiarply  defined  areas,  and  occurs  at  definite  times  and 
seasons. 

DISTRIBUTION. 

The  United  States  only. 

In  Montana  it  is  found  along  the  Bitter  Root  valley,  at  Rock 
Creek,  and  Bridger. 

In  Idaho  throughout  the  entire  valley  of  the  Snake  River  and  its 
tributaries. 

In  Wyoming  at  Cody  and  Meeteeste. 

In  Nevada,  in  the  north  only,  along  the  valley  of  the  Quinn  River. 

In  Oregon  towards  Idaho  in  the  east  only. 

The  fever  occurs  in  those  seasons  when  the  ticks  (D.  andersoni) 
are  most  prevalent. 

The  elevation  is  in  all  cases  between  3,000  and  4,000  feet  above 
sea-level. 

AETIOLOGY. 

The  causative  parasite  is  stated  to  be  localized  in  the  endothelial 
cells  and  smooth  muscle  fibres  (Wolback).  Its  exact  nature  is  not 
known. 

The  organism  is  said  to  be  present  in  the  blood-vessels  of  man, 
monkeys,   rabbits,   guinea-pigs  and  ticks. 

The  virus  cannot  be  separated  from  the  blood  cells  by  washing, 
neither  will  it  pass  through  a  Berkefeld  filter. 

One  attack  produces  immunity. 

The  virus  can  be  acquired  and  transmitted  by  the  larvae,  nymph, 
male  and  female  adults  of  D.  andersoni. 

Other  ticks  are  also  suspected. 

Men  are  more  frequently  attacked  than  women,  commonly  from 
fifteen  to  fifty  years  of  age.  Hence  with  out-door  work  there  is  greater 
risk  of  infection. 

Jack  rabbits  and  deer  mice  are  important  hosts  of  the  carrier  ticks 
as  well  as  domestic  animals. 

PATHOLOGY. 

Post  mortem,  rigor  mortis  is  well  marked.  PetechicC  are  found  on 
the  skin. 

Tick    bites    may    be    visible.       Liver    and    spleen    are    congested, 


SPOTTED  FEl'ER    OF  THE   ROCKY   MOUNTAINS        375 

enlarged  and  soft.  Kidneys  are  congested,  sometimes  with  sub- 
capstilar  haemorrhages. 

Microscopically  one  finds  capillary  congestion  of  the  viscera  with 
excess  of  leucocytes.     Extravasation  into  and  pigmentation  of  the  skin. 

Acute  parenchymatous  degeneration  of  heart  muscle,  spleen,  liver 
and  kidneys. 

SYMPTOMATOLOGY. 

Incubation. — Two  to  seven  days. 

Prodromata. — Pains  radiating  from  irritating  tick  bites,  malaise, 
nausea. 

Oiisc't. — Fairly  sudden  with  chill,  severe  headache,  pains  in  back, 
temperature  103°  to  104°  F.,  furred  tongue,  dried  skin,  congested  con- 
junctiva?, dry  cough,  epistaxis,  febrile  urine. 

Course. — Temperature  gradually  rises  to  105°  to  107°  F.  from  the 
sixth  to  the  twelfth  day. 

There  is  an  eruption  about  the  third  day  on  the  wrists  and  ankles, 
co\ering  the  bod}-  in  two  days. 

The  macules,  i  to  5  mm.  in  diameter  are  not  raised,  at  first  they 
disappear  on  pressure,  then  become  permanent  and  later  petechial, 
sixth  day.     There  is  also  a  dusky  red  mottling  of  the  skin. 

In  very  mild  cases  the  eruption  may  be  absent. 

The  pulse  is  no  to  150,  becomes  weaker,  often  dicrotic  and  may 
be  irregular.  There  is  a  slight  reduction  of  the  red  cells  and  hb.  with 
a  slight  increase  of  leucocytes. 

In  severe  cases  oedema  of  the  face  and  limbs  may  be  present. 

Constipation  is  troublesome. 

There  may  be  mild  bronchitis  with  a  slight  increase  in  respiration. 

The  urine  may  show  a  trace  of  albumin  with  a  few  granular  casts  or 
it  may  be  suppressed  in  bad  cases. 

From  the  fifth  to  the  twelfth  day  the  tvphoid  state  may  lead  to 
death. 

If  not,  then  lysis  about  the  eighteenth  day  and  convalescence. 

COMPLICATIONS. 

Pneumonia  is  common. 

Gangrene  of  the  fingers  and  toes  and  the  skin  of  the  penis  and 
scrotum  may  occur. 

Nephritis,   cardiac  weakness  and  meningitis  are  not  unknown. 

DIAGNOSIS. 

Typhoid  fever  may  be  troublesome.  It  has,  however,  a  more  in- 
sidious onset,  the  nature  and  commencement  of  the  rash  are  difTerent, 
there  are  intestinal  symptoms  and  a  Widal  reaction  can  be  done. 


376  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

Typhus  fever  ends  by  crisis,  otherwise  they  are  almost  indistinguish- 
able. 

Two  varieties  of  the  same  organism  are  possibly  the  causes  of  both 
diseases. 

Japanese  river  fever  may  be  very  similar,  but  one  should  look  for 
one  or  more  eschars  near  the  genitals  or  the  axilla  in  this  disease. 

The  eruption,  which  begins  on  the  face,  does  not  become  petechial. 

PROGNOSIS. 

In  Montana  the  mortality  is  about  go  per  cent,  and  is  always  high. 
In  Idaho  the  mortality  is  about  2*5  per  cent.,  always  low. 
The  outlook  is  good  when  the  eruption  is  not  general  and  poorly 
defined, 

TREATMENT. 

Remove  the  tick  by  applying  ammonia,  turpentine,  kerosene  or 
carbolized  vaseline. 

Cauterize  the  bite  with  pure  carbolic  acid. 

Cold  applications,  Dover's  powders,  &c.,  for  the  headache. 

Cold  sponging  for  hyperpyrexia. 

Cardiac  stimulants  may  be  necessary. 

Avoid  the  districts  where  the  disease  is  prevalent. 

Destroy  the  ticks  and  their  breeding  places  as  far  as  possible. 

In  Montana  they  practise  the  following  measures  :  — 

(i)  The  reclamation  and  cultivation  of  arable  land. 

(2)  The  burning  over  of  the  foot-hills. 

(3)  The  killing  of  wild  animals. 

(4)  Hand  picking  and  the  dipping  of  domestic  animals  in  arsenical 
dips. 

(5)  Sheep  grazing. 

(6)  The  destruction  of  ground  squirrels  by  the  use  of  carbon  bisul- 
phide pumps. 

DENGUE. 
DEFINITION. 

An  acute  specific,  infective,  non-contagious  fever  of  unknown 
causation,  spread  by  the  bite  of  the  Culex  fatigans  and  Stegomyia 
fasciata,  characterized  by  two  febrile  paroxysms,  the  pulse  varying 
directly  with  the  temperature,  and  a  marked  leucopenia. 

DISTRIBUTION. 

In  tropical  and  sub-tropical  zones  where  the  Culex  fatigans  abounds. 

In  Egypt,  Arabia,  Persia,  India,  Burmah,  Indo-China,  China, 
North  America,  Spain,  Peru,  West  Indies,  West  Africa,  Fiji  Islands, 
Western  Australia,   Ceylon. 


DENGUE  377 

An  epidemic  or  pandemic  takes  place  about  every  twenty  years 
(Manson). 

Often  75  per  cent,  of  the  population  are  attacked. 

It  prefers  the  coast  line,  deltas  and  valleys  of  great  rivers,  but  there 
are  many  exceptions  to  this. 

In  1870  to  1873  it  spread  all  over  India. 

iETIOLOGY. 

An  unknown  organism  living  in  the  blood  is  the  cause. 

An  intravenous  injection  of  20  c.c.  of  dengue-fever  blood,  filtered 
or  unfiltered,  produces,  after  an  incubation  of  two  to  three  days,  the 
typical  symptoms  of  the  disease. 

This  organism  passes  through  a  filter  which  will  retain  M.  melit- 
ensis,  the  filtrate  producing  the  fever. 

Some  people  appear  to  have  natural  immunity  against  the  disease. 

An  attack  produces  a  temporary  acquired  immunity. 

Hot  countries  suffer  most.     Cold  limits  the  disease. 

SYMPTOMATOLOGY. 

Incubation,  two  to  six  days. 

Prodromata  are  usually  absent. 

Onset  is  sudden,  introduced  often  by  some  severe  cold,  extreme 
fatigue,  deep  flushing  of  the  face,  a  shivering  in  man,  convulsions  or 
delirium  in  children. 

Initial  fever  commences  with  a  rapidly  rising  temperature,  103*-*  to 
106°  F.,  pulse  quickens,  90  to  140,  buccal  mucosa  becomes  congested, 
conjunctivae  injected,  while  occasionallv  vomiting  and  diarrhoea  are 
present. 

Severe  pains  in  the  head,  eyeballs,  lumbar  region  and  legs. 

Joints  when  moved  actively  cause  agonizing  pain,  but  when  moved 
passively  are  almost  painless,  hence  the  pain  is  really  caused  by  the 
adjoining  muscles.     Very  rarely  are  the  joints  red  and  swollen. 

The  patient  may  be  unable  to  w^alk  because  of  the  pains. 

Gastric  disturbance  and  vomiting  may  occur. 

The  lymphatic  glands  are  not  enlarged. 

Insomnia  and  delirium  are  not  infrequent. 

Leucopenia  is  almost  constant,  3,800  per  c.mm. 

The  small  lymphocytes  are  increased  and  the  polvmorphonuclears 
decreased.     OtherAvise  the  blood  is  normal. 

Intermission  or  remission  then  occurs  from  the  second  to  the  fourth 
day  as  a  rule.  The  temperature  falls  by  crisis,  accompanied  bv  profuse 
perspiration,  diuresis,  diarrhoea,  and  sometimes  epistaxis.  The  latter 
relieves  the  headache  at  once.  The  pains  almost  disappear  and  the 
patient  may  be  able  to  resume  his  work. 


378  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

In  some  cases  ihe  lemperature  remits  only  to  ioo°  or  102°  F.,  and 
the  symptoms  abate  only. 

Terminal   fever   and  eruption.     This   occurs   about    the    fifth    day, 

temperature  rises  tO'  102°  or  103°  F.,  the  pains  return  and  are  severe,  a 

rash  appears  on  the  palms  and  the  backs  of  the  hands,   elbows  and 

knees,  rapidly  spreading  to  the  trunk  and  legs.     This  rash  may  be  :  — 

(i)  A  measly  eruption,  small  circular  dusky  patches. 

(2)  A     scarlatiniform    eruption,     numerous     bright     red,     small 
papules  forming  larger  patchy  areas. 

(3)  A  mixed  type  or  abortive  only. 

The  eruption  lasts  two  to  eight  days  followed  by  a  furfuraceous  des- 
quamation lasting  two  or  three  weeks. 

The  second  temperature  falls  by  crisis  about  the  sixth  day. 

The  pains  may  come  back  again  at  intervals  for  weeks  afterwards. 

Convalescence  may  be  C]uick  and  permanent  or  protracted  and  com- 
plicated. 

The  seven-day  fever  of  Rogers  is  held  by  some  to  be  a  varietv  of 
Dengue. 

The  mortality  is  almost  nil  (o'l  per  cent). 

SEQUELS  AND   COMPLICATIONS. 

Relapses  are  not  uncommon. 
Pains  in  the  joints  and  muscles. 
Hcemorrhage  from  any  of  the  mucous  membranes. 
Hyperpyrexia   is   rare,   so  also  are  pleurisy,    pericarditis,    orchitis, 
endocarditis  and  meningitis. 

DIAGNOSIS. 

Look  for  sudden  onset,  severe  muscular  pain,  intermission  on  the 
third  day,  and  rash  on  the  fifth  or  sixth  day. 

Yellow  fever  has  its  low  pulse  with  a  high  fever,  jaundice  and 
haematemesis. 

Influenza  has  catarrhal  symptoms,  and  rash  is  absent. 

Scarlet  fever  has  sore  throat  and  enlarged  cervical  glands. 

Measles  has  catarrhal  symptoms,  but  no  severe  muscular  pains. 

Rheumatic  fever  has  swollen  joints. 

Small-pox  will  be  difficult  until  the  eruption  is  seen. 

Early  enteric  cases  are  not  easy  to  distinguish;  the  cause  of  the 
fever  will  decide  it. 

TREATMENT. 

It  is  useless  to  attempt  to  cut  the  fever  short. 
Cool  applications  to  the  forehead  for  headache. 
Dover's  powder  or  morphia  for  the  pain. 


TYPHUS    FEVER  379 

Stimulants  should  be  avoided. 

Purgatives  and  emetics  tend  to  increase  the  muscular  pain. 
Massage.     Electricity  and  iodides  can  be  applied. 
Change  of  air  and  place  are  necessary. 

TYPHUS    FEVER. 
DEFINITION. 

An  acute  specific  contagious  fever  of  unknown  causation,  charac- 
terized by  sudden  onset,  marked  nervous  symptoms,  macular  eruption 
terminating  by  crisis. 

DISTRIBUTION. 

It  is  a  disease  of  temperate  and  cold  climates,  but  in  the  tropics  it 
may  occur  in  high  altitudes  and  during  cool  seasons. 

It  is  present  in  Xubia,  Egypt,  Tripoli  and  Morocco,  Asia  Minor 
and  Persia,  and  from  thence  to  India. 

It  is  also  found  in  North  China  and  Hiogo,  Japan. 

It  is  endemic  in  Mexico  and  common  in  Peru  and  North  Chili. 

It  is  prevalent  among  the  Balkan  States  and  Austria,  who  lost 
30,000  of  150,000  cases. 

It  has  been  present  in  Ireland  for  centuries. 

In  Egypt,   1914-1915,  there  were  23,855  cases  with  6,132  deaths. 

^ETIOLOGY. 

The  specific  organism  is  unknown.     It  exists  in  the  blood,  which 
is  virulent  from  the  third  to  the  tenth  day  of  the  attack  (Nuttall). 
The  disease  has  been  transmitted  to  apes  by  typhus  blood. 
Human  body  lice  carry  the  causative  organism. 
It  is  associated  with  dirt  and  filth. 

SYMPTOMATOLOGY. 

Incubation  about  twelve  days. 

Onset  sudden,  frontal  headache,  pains  in  body,  sometimes  in  chest, 
temperature  rises  rapidlv,  101°  to  104°  F.,  pulse  Cjuick,  100  to  120,  face 
flushed,  appearance  dull,  heavy  and  pathetic. 

Tongue  thickly  furred,  rapid  exhaustion,  a  mousy  odour  from  the 
skin.     Delirium  sometimes  early. 

Rash  on  abdomen  or  chest  about  the  fifth  day.  At  first  a  transient 
erythema,  then  a  macular,  measly  eruption,  followed  by  the  petechial 
form.  The  rash  is  mild  or  absent  in  20  per  cent,  of  cases.  When 
present  it  covers  the  whole  body  quickly,  except  the  face,  palms  and 
soles. 

The  typhoid  state  comes  on  rapidly  with  low  muttering  delirium. 

The  pupil,  before  contracted,  is  now  dilated. 


38o  DISEASES  OF  UNCERTAIN  ETIOLOGY 

The  urine  may  be  detained. 

Paralysis  of  the  sphincters  or  grave  complications  terminate  the 
attack. 

About  the  thirteenth  or  fourteenth  day  the  fever  terminates  by  crisis, 
profuse  sweating,  critical  diarrhoea  and  diuresis,  with  excess  of  urates. 

Convalescence  then  begins. 

Second  attacks  are  rare. 

COMPLICATIONS. 

Bronchitis,  Broncho-pneumonia,  Retention  of  urine.  Hyperpyrexia, 
Parotid  bubo,  Pyasmic  abscesses.  Thrombosis  of  femoral  vein,  Bed 
sores.  Gangrene  of  extremities.  Relapsing  fever  and  Acute  miliary 
tuberculosis. 

TREATMENT. 

Good  air  and  plenty  of  it  is  essential  for  this  disease. 

Shield  the  eyes  from  excessive  light. 

Liquid  and  bland  foods  should  be  given  as  they  can  be  assimilated. 

All  noise  in  the  sick  room  should  be  avoided. 

Strychnine,  digitalin,  &c.,  are  necessary  for  the  heart. 

Hyoscine,  bromides,  or  morphine  may  be  required  for  nerve 
symptoms. 

20  c.c.  intravenously  of  the  serum  from  patients  who  have  been 
convalescent  twelve  days  have  been  useful  in  some  cases;  repeated  if 
necessary. 

All  clothing  must  be  thoroughly  disinfected  at  once. 

All  hair  must  be  shaved  ofif  and  the  whole  body  thoroughly 
cleansed.     No  lice,  no  t3^phu9. 

H^MOGLOBINURIC    FEVER    (Blackwater   Fever). 

DEFINITION. 

An  acute  fever  of  uncertain  causation  characterized  bv  excessive 
blood  destruction,  jaundice,  h^emoglobinuria,  diminution  and  sup- 
pression of  urine. 

DISTRIBUTION. 

Most  commonly  in  tropical  Africa  and  parts  of  India. 

It  is  less  commonly  found  in  South  Italy,  Sicily,  Greece,  Asia 
Minor,  Southern  Russia,  China,  Siam,  Malay  Peninsula  and  the 
Southern  regions  of  the  United  States.  Central  and  South  America 
and  Brazil  in  particular,  West  and  East  Indies,  and  Polynesia. 

It  is  extremely  rare  in  the  Roman  Campagna,  the  classic  land  of 
malaria. 

Its  endemicity  is  said  to  be  limited  to  low  swampy  grounds. 


HJEMOGLOBINURIC   FEVER  381. 

It  appears  to  have  some  dependence  upon  meterological  conditions. 
It  attacked  the  Chinese  labourers  when  building  the  Congo  railway. 
It  attacked  the  labourers  constructing  the  Corinth  canal. 
It  attacked  the  Chinese  army  at  Kwangsi  like  a  plague. 
It  attacked  the  prisoners  in  Sardinia  in  1885. 

AETIOLOGY. 

Theories. — These  are  numerous.     The  chief  are  as  follows  :  — 
(i)  A  manifestation  of  an  active  malarial  infection. 

(2)  The  result  of  quinine  poisoning. 

(3)  That  it  is  due  to  a  specific  organism. 

(4)  That  it  is  a  condition  brought  about  by  previous  malarial 
infection. 

(1)  That  it  is  a  Manifestation  of  an  active  Malarial  Infection. 
Pro.     It  has  been  pointed  out  :  — 

(i)  That  where  the  malarial  mortality  is  high,  blackwater 
fever  is  not  uncommon,  but  it  is  scarce  where  the 
malarial  mortality  is  low. 

(2)  That  people  attacked  with  blackwater  fever  had  pre- 
viously suffered  from  malaria  and  had  usually  been 
attacked  several  times. 

(3)  That  the  day  preceding  the  hsemoglobinuria  the 
patient's  blood  contained  parasites  in  95'6  per  cent,  of 
cases,  while  the  day  after  the  attack  they  were  seen  in 
only  1 7" I  per  cent,  of  cases  (Stephens). 

(4)  That  there  is  found  a  monoieucocytosis. 
Con  :  — 

(i)  That  it  has  occurred  in  people  who  have  never  had 
malaria. 

(2)  That  it  is  uninfluenced  bv  quinine. 

(3)  That  in  Panama  h^emoglobinuria  is  rare,  but  acute 
malarial  infection  very  common.  This  view  is  not 
widely  held.  Most  seem  to  agree  that  acute  malaria 
may  be  the  exciting  factor,  but  that  some  other  agent 
is  necessary. 

(4)  That  blackwater  is  rare  in  some  districts  where  malaria 
is  most  rife. 

(2)  That  it  is  the  Result  of  Quinine  Poisoning  (Koch). 
This  view  is  not  widely  held  because — 

Quinine  administered  to  patients  without  previous  malaria  has  never 
caused  hasmoglobinuric  fever,  no  matter  how  great  the  dose. 

H^moglobinuric  fever  has  occurred  when  no  quinine  has  been 
administered. 


382  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

The  taking  of  quinine  does  sometimes  determine  blackwater,  but 
much  more  often  it  does  not. 

Blackwater  fever  was  known  to  Europe  by  Hippocrates  and  others 
long  before  cinchona  bark  was  imported. 

Some  assert  that  quinine  will  improve  and  in  some  cases  cure  the 
condition. 

(3)   That  it  is  due  to  a  Specific  Organism. 

Sambon  in  1898  proposed  a  Babesia. 

Many  parasites  have  been  described  since.     The  idea  perhaps  arose 
because  of  a  somewhat  similar  disease  in  animals  caused  by  a  piro- 
plasmosis.     The  similarity  unfortunately  is  only  superficial  for  :  — 
With  hcemoglohinuria  in  animals — 

It  depends  upon  infection  by  a  definite  organism. 

That  organism  is  present  in  numbers  proportional  to  the  severity 

of  the  disease. 

Its  insect  host  is  well  known. 

No  previous  illness  is  necessary  or  usual  before  the  disease  is 

manifested. 

If  the  animal  recovers,  immunity  for  it  is  established. 

All  non-immune  animals  sufifer  in  proportion  to  their  exposure 

to  the  infection. 

The  symptoms  are  progressive  as  a  rule,  little  blood  at  first,  but 

more  later. 

There  is  no  natural  immunity. 
With  hcemoglohinuria  in  man — 

No  organism  except  the  malarial  parasite  is  constantly  found. 

Where  malarial  fever  is  absent  hcemoglohinuria  is  absent  also. 

Those  races  relatively  immune  to  malaria  are  relatively  immune 

to  blackwater. 

One  attack  of  hcemoglohinuria  does  not  produc«!  immunity,  but 

perhaps  increasingly  tends  to  predispose  to  another  attack. 

The   writer    had   a    patient   with   three   attacks    within    eighteen 

months,  each  one  increasingly  dangerous. 

Relapses  are  not  uncommon. 

Most  blood  is  usually  passed  early;  the  amount  diminishes  with 

the  disease. 

That    it    is   not   in    the    least    infective   is   against    its   being   of 

parasitic  origin. 

Hasmoglobinuria  is  so  acute  that  the  parasite,   if  one  there  is, 

must  be  numerous  and  possessing  high  powers  of  vitality. 

There  may  be   long  interv^als  between  two   cases   in   the  same 

district.     If  a  parasite,  how  does  it  survive? 


H^MOGLOBINURIC    FEVER  383 

(5)  That  it  is  a  Condition  brought  about  by  a  previous  Malarial 
Infection. 

A  case  of  h^emoglobinuria  usually  gives  a  history  of  one  or  more 
attacks  of  malaria.  Small  doses  of  cjuinine  in  some  such  Central 
African  patients  is  sufficient  to  precipitate  the  disease  (Sandwith). 

The  subtertian  parasite  seems  to  be  usually  the  parasite  of  the 
malaria.  This  accounts  for  the  statement  that  malaria  (benign  tertian 
or  cjuartan)  may  be  prevalent,  but  no  h^emoglobinuria. 

The  Ancon  Hospital  Records  show  that  malaria  complicates  prac- 
tically every  other  disease,  but  neither  clinically  nor  at  autopsy  has 
blackwater  fever  complicated  any  infectious  disease  other  than  malaria. 
In  not  one  case  of  blackwater  can  evidence  of  malaria,  either  remote 
or  immediately  prior,  be  excluded  (Decks  and  James). 

The  hiemoglobinuria  seems  to  be  a  h^emolytic  toxic  action. 

Subtertian  malaria  has  a  strong  toxic  action,  as  evidenced  by  the 
cytolytic  action  upon  the  kidney  cells  and  the  parenchymatous  focal 
neurosis  of  other  viscera.  Haemolysis  is  closely  allied  to  cytolysis,  in 
the  former  case  the  cells  of  choice  being  the  erythrocytes.  25  per  cent, 
of  the  red  cells  may  be  destroyed  as  a  result  of  one  paroxysm  of  sub- 
tertian malaria.  Although  the  life  of  a  red  cell  is  perhaps  only  four 
weeks  and  the  whole  is  regenerated  every  twenty-eight  days,  the 
vascular  system  could  not  long  stand  the  strain. 

The  writer  had  a  case  that  gave  850,000  red  cells  per  cubic  millimetre 
the  second  day  of  the  fever. 

In  studying  230  cases  of  hcemoglobinuric  fever  at  Ancon  Hospital, 
Decks  and  James  write  their  views  thus  :  — 

An  haemolysis  has  two  groups,  a  combining  and  a  destructive 
group.  The  first  must  unite  with  the  cell  before  the  latter  can  destroy 
it.     The  exciting  factors  are  :  — 

(i)  Renewed  malarial  paroxysms  to  produce  sufficient  toxin  to 
overwhelm  the  cells. 

(2)  Then  a  lowering  of  body  resistance. 

(3)  The  adiliinistration  of  ciuinine  which  may  act  in  either  of  two 
ways  :  — 

By  depressing  the  vital  processes  of  the  bodv,  or 
By  acting  as  the  toxophore  radical  of  the  h^emolvsis. 
No  regularity  of  results  following  the  administration  of  ciuinine 
can  be  predicted.  H^emoglobinuria  has  followed  the  taking  of  i  grain 
of  quinine,  in  others  it  has  not  resulted  after  taking  30  grains  over 
several  days,  but  it  does  not  occur  except  in  tliose  who  have  had  a 
previous  attack  of  malaria. 

Forty-two  thousand  cases  admitted  for  diseases  other  than  malaria 
did  not  develop  one  single  case  of  blackwater.     94-6  per  cent.  (246)  of 


384  DISEASES  OF  UNCERTAIN  ETIOLOGY 

blackwater  patients  showed  one  or  more  previous  attacks  of  malaria. 
In  230  cases  subtertian  parasites  were  found  in  76'4  per  cent,  of  cases^ 
and  benign  tertian  in  23*6  per  cent,  of  cases. 

Most  of  the  cases  develop  after  twelve  months'  residence  in  the 
tropics.  After  three  to  four  years'  residence  in  an  endemic  region  the 
ha^moglobinuric  rate  diminishes,  hence  length  of  residence  appears  to 
be  a  factor.     Decks  and  James  sum  up  their  investigations  thus  :  — 

(i)  Hiemoglobinuric  fever  is  a  manifestation  of  malarial  toxicity, 
for  the  most  part  brought  about  by  repeated  attacks  of  malaria. 

(2)  It  mav  appear  coincidentally  with  an  acute  malarial  paroxysm. 

(3)  It  mav  be  determined  by  any  depressing  influence. 

(4)  It  mav  be  induced  by  the  administrations  of  quinine. 

(5)  Neither  quinine  alone,  nor  malarial  infection  alone,  causes 
hccmoglobinuria,  but  one  or  both  of  these,  plus  the  toxin 
eventuated  during  the  course  of  one  or  more  malarial  attacks. 

(6)  Syphilis  is  a  predisposing  factor,  because  of  its  influence  in  the 
production  of  malarial  recrudescences. 

(7)  The  treatment  varies  with  the  condition  present. 

(8)  To  ensure  against  the  recurrent  attacks  of  malaria,  with  the 
subsequent  production  of  hasmoglobinuric  fever,  it  is  necessary 
to  raise  the  patient's  resistance  to  a  maximum,  and  to  eradicate 
the  malaria  by  a  thorough  course  of  treatment  with  quinine. 

There  is  no  proof  that  it  has  spread  from  one  country  to  another ;  on 
the  contrary,  the  disease  manifests  itself  when  certain  conditions 
relative  to  the  epidemiology  of  malaria  and  to  that  of  no  other  disease 
are  present. 

The  conditions  are  :  — 

(i)  The  presence  of  a  population  non-immune  against  malaria. 

(2)  The  prevalence  of  malaria  in  such  quantity  as  to  produce  an 
almost  continuous  infection   in  this  population. 

(3)  A  large  proportion  of  subtertian  malaria,  because  the  amount  of 
blackwater  fever  is  in  direct  proportion  to  the  intensity  of  this 
variety. 

(4)  The  neglect  of  prompt  and  continued  administration  of  quinine, 
especially  in  primary  attacks,  to  persons  non-immune  against 
malaria. 

In  every  locality,  without  exception,  where  these  conditions  obtain, 
hcemoglobinuric  fever  is  found  (Deeks  and  James). 

PATHOLOGY. 

Christophers  and  Bentley,  working  on  the  malarial  theory,  put 
forward  the  following  views  :  — 

(i)  Laverania  malari^e,  the  subtertian  parasite,  acts  upon  the  endo- 


H^MOGLOBINURIC   FEVER  385 

thelial  cells  of  the  blood  capillaries,  stimulating  them  to  excessive 
destruction  of  red  blood  cells  by  phagocytosis. 
(2)  This    phagocytosis    results    in    the    production    of    an    auto- 


Diagrammatic  representation  of  the  condition  of  the  kidney  in  health  (A),  during 
experimental  hemoglobinuria  of  rabbit  (B),  and  in  suppression  of  urine  following  upon 
blackwater  fever  (C).  In  B  small  casts  are  present  in  some  of  the  uriniferous  and 
collecting  tubules  ;  in  C  large  casts  are  present  in  many  of  the  uriniferous  and  collecting 
tubules.  In  the  latter,  considerable  enlargement  of  the  kidney  is  also  observed.  For  the 
sake  of  comparison  B  is  represented  as  tri-papillary  instead  of  being  uni-papillary,  as  in  the 
rabbit. — (From  the  "  Annals  of  Tropical  Medicine  and  Hygiene,"  Liverpool  University, 
by  permission.) 

h^emolysin  retained  in  the  endothelial  cells  until  set  free  by  some 
exciting  cause  as  chill,  over-exertion,  &c. 

(3)  The  hc'emolysin  is  then  suddenly  set  free  and  destroys  the  red 
cells  by  solution  in  the  plasma,  principally  in  the  blood  of  the 
liver,  kidney  and  spleen. 

(4)  This  lysiemia  produces  h^emoglobinaemia,  quickly  appearing  in 
the  urine  as  oxyh^emoglobin,  which  may  become  meth- 
haemoglobin  on  standing. 

(5)  Some  of  it,  the  liver  probably  converts  into  bile;  the  remainder 
passes  out  in  the  urine. 

(6)  Large  coarsely  granular  casts  in  the  ducts  of  Bertini  mechani- 
cally block  the  tubules  and  cause  suppression  of  urine  (Barrett). 


JOU 


Plahn  believes  it  to  be  the  result  of  nervous  inhibitioi 
glomerular  secretion.    Others  suppose  it  is  the  result  of  i 


Diagrammatic  representation  of  a  renal  lulmle.  (A)  normal;  (B)  co:-nmencing  d( 
h£emoglobinuria  ;  (C)  sufficient  deposit  to  be  washed  on  and  cause  obstruction  of  t^ 
the  pyramid.  (After  J.  O.  Wakelin  Bariatt  and  Warrington  Yorke.)— From  the  ' 
of  Tropical  Medicine  and  Hygiene;'  Liverpool  University,  by  permission. 

caused  by  the  disease.  The  improvement  of  the  conditi 
the  B.P.  is  raised,  as  when  after  salines  are  given,  supi 
mechanical  theory. 

P.M. 

The  cardinal  features  are  :  — 

Jaundice  of  the  tissues. 

Liquid  blood. 

Swollen  and  congested  kidneys. 

The  kidneys  are  enlarged,  dark  red,  degenerated  tubular  epi 
the  tubules  block  with  granular  material. 

The  liver  is  enlarged,  the  gall-bladder  full  of  inspissated  bi 
of  livf;r  necrosis  with  thrombi  in  the  sub-lobular  veins,  and  h^em 
in  the  cells. 

The  bone-marrow  is  yellowish,  fluid,  or  gelatinous. 


ESSENTIALS    OF   TROriCAL   MEDICINE. 

BLOOD-SPECTRA    COMPARED    WITH    SPECTRUM    OF 

ARGAND-LAMP. 


Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 
Spectrum  of 


Most    of    the    above 


Argand'lamp  with  Fraunhofer  lines  in  position. 

Oxyhaemoglobin   in  diluted   blood. 

reduced   Haemoglobin. 

carbonic  oxide   Haemoglobin. 

acid   Haematin   in  etherial  solution. 

alkaline   Haematin. 

Chloroform  extract  of  acidulated   Ox-bile. 

Methaemoglobin   (alkaline. ) 

Haemochromogen. 

Haematoporphyrin. 

Spectra    have    been    drawn    from    observations   by 
Mr,     NA/.     LEPRAIK.   F.C.S. 


Face  page  386, 


HEMOGLOBIN  URIC   FEVER  387 

The  blood  is  thin,  watery,  diminished  tonicity,  red  cells  and  hb, 
much  reduced  showing  degenerative  changes.  Malarial  parasites  or 
pigment  may  be  seen. 

There  is  leucocytosis  during  the  fever,  leucopenia  with  a  mono- 
nuclear increase  afterwards. 

The  urine  is  yellow,  dark  red,  blackish.  Diluted,  the  spectroscope 
shows  oxy-  or  meth-ha?moglobin,  low  specific  gravity,  a  dark  brown 
granular  deposit  from  destroyed  blood  cells.  When  boiled  and  allowed 
to  stand  for  some  time  a  bright  purple  colour  develops  (Plhen's 
reaction).     The  urine  does  not  decompose  for  some  time. 

Albumin  is  plentiful.  Phosphates  are  diminished.  Urobilin  can 
be  seen  with  the  spectroscope  after  acidulating  the  urine  with  acetic 
acid  and  extracting  witli  amyl  alcohol. 

SYMPTOMATOLOGY. 

As  a  rule  the  patient  has  had  recurrent  malarial  attacks,  and  has 
taken  quinine  spasmodically  or  not  at  all.  White  people  are  more 
prone  to  it  than  coloured. 

Prodromata  are  often  absent.  When  present  there  mav  be  lassi- 
tude, general  pains,  loss  of  appetite,  restlessness,  yellow  tinging  of 
skin  and  conjunctivae. 

Course:  shivering  fits,  headache,  severe  pains  in  back,  hiccough, 
nausea,  retching,  vomiting  food,  then  green  bile.  Excessive  thirst,, 
constipation,  urgent  desire  to  micturate.  Liver  and  spleen  tender, 
skin  hot  and  dry,  yellow  skin  and  conjunctiva.  Temperature  rises 
rapidly  to  io3°-i04°  F.,  pulse  100-120,  small,  regular,  readily  com- 
pressible.    Blackish  urine  with  burning  sensation  of  the  urethra. 

After  a  few  hours  perspiration  sets  in,  temperature  falls  to  100°  F., 
the  urine  clears,  convalescence  begins,  or  in  a  severe  case  vomiting 
increases,  temperature  again  rises,  diarrhoea  sets  in  with  bilious 
motions  and  blood.  Some  recover,  others  die  of  exhaustion,  hyper- 
pyrexia, coma,  anuria,  and  ura?mia  as  a  result  of  this  or  successive 
attacks. 

In  any  cases  of  recovery  convalescence  is  much  protracted. 

There  is  always  grave  anaemia. 

The  mortality  varies  from  4  per  cent,  to  50  per  cent. 

The  figures  on  the  West  Coast  are  of  interest,  as  compared  with 
those  of  East  Africa  and  Nyasaland  :  — 


Gold  Coast             

.     21 

cases     ... 

r  cent. 

mortality 

Sierra  Leone 

10 

lO'O 

Southern  Nigeria 

.     21 

...     23-8 

Northern  Nigeria  ... 

17 

•••     35'-9 

East  Africa  Protectorate  . 

i^ 

...     26-6 

Uganda       

58 

...       20'0 

') 

Nyasaland 

7 

...    14-2 

1' 

388  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

The  urine  is  dark  brown,  acid,  separates  on  standing  into  two 
layers,  the  upper  clear  or  port-wine  colour,  the  lower  brownish  grey 
with  hyaline,  and  hb.  tube  casts  and  debris.  Red  cells  are  few  or 
absent. 

Epithelial  cells  may  be  seen. 

TREATMENT. 

Rest  in  bed  is  absolutely  necessary  with  the  best  nursing  available. 

The  patient  must  not  move  if  the  attack  is  severe. 

All  kinds  and  plenty  of  bland  fluids  as  the  stomach  will  retain  them. 

Calomel  followed  by  mag.  sulph.  can  be  given  with  care. 

Hot,  moist  applications  over  the  stomach  and  loins  and  hot-air 
baths  are  always  good. 

If  parasites  are  present  cjuinine  is  indicated,  but  the  results  must 
be  watched.  If  the  condition  is  aggravated  withdraw  it  for  a  few  days, 
and  then  repeat  it. 

The  chief  essential  indications  are  :  — 

(i)  To  flush  the  kidneys. 

(2)  To  raise  the  blood-pressure. 

(3)  To  strengthen  the  heart. 

Give  digitalin,  ergotin  and  morphia  for  the  vomiting  when  present. 

Normal  salines,  and  plenty  oj  them,  must  be  given  one  way  or  other. 

These  can  be  given  per  rectum  with  a  rubber  catheter  well  inserted  ; 

Or,  and  also  subcutaneously,  8  to  16  ounces  every  three  hours; 

Or,  and  also  intravenously  (Rogers),  four  pints  at  a  time. 

Some  claim  good  results  from  salvarsan  given  in  two  pints  of 
saline  (Burkitt). 

Burkitt  and  MacGilchrist  agree  that  the  cause  may  be  due  to 
increased  alkalinity  of  the  blood,  in  consequence  of  which  the  former 
administered  potassium  and  sodium  bicarbonates  with  success,  giving 
them  in  i  drachm  doses  hourly  in  plenty  of  water. 

When  the  danger  is  past  give  some  mild  ferruginous  preparation, 
followed  by  Fowler's  solution. 

Syphilis  when  present  must  be  treated  as  soon  as  possible. 

The  patient  should  leave  the  district  early  and  advised  not  to  return. 

The  saline  treatment  is  all-important.  Fluid  must  be  passed  into 
the  circulation.  It  is  useless  to  give  pilocarpine  when  the  blood  has 
little  fluid  to  give  up  and  the  kidneys  already  exhausted  by  the  lack 
of  it. 

All  urine  must  be  carefully  measured  and  the  time  noted  when 
passed. 

If  the  amount  is  decreasing  put  in  more  fluid  by  mouth,  rectum, 
subcutaneouslv    or    intravenouslv,    until    the   amount    increases   to   the 


FA  VISM  389 

normal,  hut  an  excess  of  fluid  injected  and  none  excreted  may  so  over- 
tax the  heart,  already  weak,  as  to  cause  sudden  death. 

A  red  cell  count  should  be  done  every  other  day,  and  the  move- 
ments of  the  patient,  such  as  sitting  up  and  using  the  bed-pan,  &c., 
must  be  controlled  thereby.  To  attempt  to  Avalk  too  early  may  cause 
sudden  death. 

Exercises  should  be  graduated  and  permitted  according  to  the  red 
cell  regeneration,  this  being  a  much  safer  guide  than  the  feelings  of 
the  patient  or  the  temperature  chart.  One  patient  mav  regenerate  in 
much  less  time  than  another. 

FAVISM. 
DEFINITION. 

An  acute  febrile  anaemia  with  icterus  and  haemoglobinuria. 

DISTRIBUTION. 

It  occurs  in  Sardinia,  and  perhaps  other  Mediterranean  ports. 

ETIOLOGY. 

Sufferers  blame  fresh  beans,  raw  or  cooked,  and  even  the  smell  of 
bean  flowers  when  in  blossom.  It  usually  occurs  in  the  season  when 
the  bean  ripens. 

SYMPTOMATOLOGY. 

A  few  hours  after  ingestion  of  beans  or  exposure  to  the  scent  of 
the  flowers  an  acute  febrile  anaemia  develops,  and  the  red  cells  may  be 
rapidly  reduced  to  2,000,000  per  c.mm.  and  the  hb.  to  20  per  cent. 
There  is  icterus;  the  liver  may  be  tender  to  pressure;  the  urine  contains 
free  hb.,  urobilin  and  indican.  The  blood-serum,  however,  is  clear 
and  does  not  contain  any  hb. 

Sometimes  there  is  bilious  vomiting  and  diarrhoea. 

Children  usually  die,  adults  recover. 

The  blood  quickly  regenerates. 

Malaria  and  quinine  can  be  excluded  from  the  causative  factors. 

Little  is  known  about  it  at  present. 

TREATMENT. 

As  for  hiemoglobinuria. 


HEAT  SYNCOPE  AND  HEAT  STROKE. 

Of   this   disease   there    are    two    groups,    which    may   be    classified 
thus  :  — 

(i)  Heat  syncope,  an  exhaustion  with  little  or  no  fever,   but  with 
some  cardiac  failure  as  a  rule. 

25 


390 


DISEASES  OF  UNCERTAIN  ETIOLOGY 


(2)   Heat    stroke  :     (a)    Direct,    with    liigh    body    temperature    after 

exposure  to   the   sun   (  =-  sunstroke). 
{b)  Indirect,    with    high    bodv    temperature   but 
exposure  to  the  sun  is  not  necessary. 
The    difference    between    heat    s}'ncope    and    heat    stroke    can    be 
tabulated  thus  (Bram)  :  — 


Heat  Syncope 

(i)  History  of  exposure  to  excessive  heat, 
usually  indoors 

(2)  Onset    gradual,    no    convulsions    or 

paralysis,  but  prodiomata  as  head- 
ache, dizziness,  nausea,  &c. 

(3)  Rarely,  loss  of  consciousness 

(4)  Skin  cool,  pale  and  clammy 

(5)  Conjunctivas  pale,  pupils  dilated  or 

normal 

(6)  Temperature    normal,   subnormal  or 

slightly  elevated  100"- 102°  F. 

(7)  Pulse  weak  and  thready 

(8)  Respiration  shallow  and  sighing 

(9)  Course    greater    in    duration,     pro- 

gnosis favourable,    usually    termi- 
nating in  recovery  in  a  few  days 

(10)  Recovery  usually  uninterrupted  and 

complete 

(11)  Usually  debilitated  by  disease 


Heat  Stroke 

History   of  direct   exposure  to  the  sun's 

rays 
Onset  sudden,   often  with   convulsions  or 

paralysis 

Usually  complete  unconsciousness 

Skin  hot,  dry,  flushed 

Injected  conjunctivae,  contracted  pupils 

Temperature  very  high,  io5'^-ii3''  F. 

Pulse  high  and  bounding 

Respirations  irregular,  often  Cheyne- 
Slokes  in  type 

Course  brief,  with  guarded  prognosis, 
terminating  in  death  or  recovery  in 
from  a  few  hours  to  a  day  or  more 

Complications  and  sequelae  not  uncommon 

Previously  in  normal  health 


(1)   HEAT  SYNCOPE. 
DEFINITION. 

Faintness  or  fainting  as  a  result  of  exposure  to  a  high  atmospheric 
temperature  associated  with  humidity  and  bad  ventilation  in  persons 
whose  bodies  have  been  debilitated  by  disease. 

vETIOLOGY. 

The  two  necessary  factors  are  ;  — 

(i)  High  wet  bulb  temperatures. 

(2)  Abnormal  bodily  health. 

This  latter  includes  any  organic  disease,  especially  chronic 
alcoholism  A\hich  causes  fatty  degeneration  of  the  heart's  muscle, 
allowing  dilatation  under  conditions  of  moist  hot  air  in  badly  ventilated 
places.  Unsuitable  clothing  and  vigorous  exercise  also  predispose. 
Alcoholism  is  the  most  potent  factor. 

SYMPTOMATOLOGY. 

The  patient  may  be  in  a  badly  ventilated  building  as  a  theatre  or 
church,  in  a  crowd,  or  wearing  unsuitable  clothing  as  soldiers  on  the 
march,  or  unduly  fatty.  The  patient  becomes  giddv,  staggers  and 
falls.     There  is  pallor,  small  pulse,  dilated  pupils,  shallow  breathing. 


HEAT  SYNCOPE   AND   HEAT   STROKE  391 

cold    skin,    temperature    normal    or    sub-normal,    partial    or    complete 
unconsciousness.     Headache  is  common. 

Death  is  the  exception. 

There  are  usually  no  after  symptoms. 

TREATMENT. 

Open  air,  apply  cold  water  to  the  face,  loosen  the  clothing  about 
the  chest.  Ammonia  salts  to  the  nose.  Brandy  to  drink.  Injection 
of  strychnine  when  necessary. 

Bed,  hot  bottles  and  stimulants  if  the  temperature  is  sub-normal. 

(2)  HEAT  STROKE  (Sunstroke). 

(A)  Direct. 
DEFINITION. 

A  febrile  condition  resulting  from  exposure  to  the  direct  rays  of 
the  sun  accompanied  by  pulmonary  congestion,  convulsions,  coma, 
recovery  or  death. 

iETIOLOGY. 

A  dog  shaved  and  exposed  to  the  direct  rays  of  the  sun,  dies.  If 
it  is  covered  with  coloured  glass,  nothing  happens. 

This  variety  is  common  in  Persia  and  India,  but  may  occur  any- 
where if  the  temperature  is  high  enough. 

The  theories  as  to  the  causation  are  :  — 

(i)  Caloric,  a  hyperpyrexia!  condition. 

(2)  Actinic,   due  to  the  sun's  chemical   rays. 

(3)  Microbic,  due  to  some  germ  (Sambon). 

(4)  Toxic,  due  to  poisons  generated  by  the  excessive  heat. 
Manson's  classification  is  as  follows  :  — 

(a)  Superheating  of  the  blood. 
(h)  Paralysis  of  the  thermic  centres  causing:  — 
(i)  Excessive  production  of  heat. 

(2)  Retention   of  body  heat. 

(3)  Expansion   of  cerebro-spinal  fluid  causing  pressure  on   tb,e 

brain. 

(4)  Vasomotor  paralysis.  ^ 

(5)  Paresis  of  heart  ganglia. 

(6)  Excess  of  carbon  dioxide  in  the  blood. 

(7)  Coagulation  of  the  mvosin. 

(8)  vSuppression  of  sweat. 

(9)  Deficient  serositv  of  the  blood. 

The  thick  skull  and  black  skin  of  negroes  are  protective. 


392  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Punioni,  who  has  done  recent  work  on  this  subject,  concludes 
thus  :  — 

The  tissues  which  compose  the  cranium  from  the  dura  mater  to  the 
skin,  are  diathermal  both  to  the  yellow-red  and  to  the  violet-ultraviolet 
rays,  but  they  absorb  the  red  and  green-blue  rays. 

Sunstroke  is  brought  about  by  the  action  of  the  violet-ultraviolet 
rays  upon  the  meninges  and  the  cerebral  substance. 

At  the  same  time,  one  must  not  completely  forget  the  red-yellow 
rays,  which  facilitate  the  photo-chemical  action  of  the  violet-ultra- 
violet rays  by  means  of  the  heat  which  they  produce. 

With  regard  to  prophylaxis  against  sunstroke,  it  is  well  to  protect 
the  susceptible  parts  (head,  neck  and  spine)  with  green  clothing,  which 
absorbs  the  violet-ultraviolet  rays  as  well  as  the  red-yellow,  letting 
pass  the  green  rays  only,  which  are  harmless  because  they  are  arrested 
altogether  by  the  tissues  of  the  cranium. 

Since  in  practice  it  is  necessary  to  combine  the  prophylaxis  against 
sunstroke  with  that  against  heat  stroke,  it  is  advisable  to  cover  the 
green,  heat-absorbing  clothing  with  white  material,  which  is  well 
known  to  possess  the  greatest  reflecting  properties. 

The  eyes  should  be  protected  by  means  of  coloured  glasses;  these 
again,  for  the  above  reasons,  should  be  green. 

SYMPTOMATOLOGY. 

The  patients  may  be  affected  in  various  ways  under  different  con- 
ditions,  thus  :  — 

(i)  One   may   have   been    marching   long    in    the   sun,    with   tunic 

fastened  up  to  the  throat,  when  there  are  headache,  convulsions, 

and  not  infrequently  incontinence  of  urine. 

(2)  Or  the  patient  may  perspire  profusely,  turn  pallid  with  rapid 
respirations  and  fall   partly   unconscious. 

(3)  Or  excessive  thirst  may  be  experienced  followed  by  coma. 

(4)  Or  a  headache  may  become  more  and  more  severe,  with  intoler- 
ance to  light;  this  may  be  followed  by  partial  coma,  with 
recovery  or  death.  If  recovery  there  is  often  headache  for  six 
or  eight  weeks. 

(5)  Or  after  prolonged  exposure  to  the  sun,  a  hot  dry  skin,  estab- 
lished intolerance  to  light,  sound  and  movement. 

There  may  be  vomiting. 
Recovery  may  be  :  — 
(i)  Sudden  and  complete. 

(2)  Or  prolonged  over  several  days  or  weeks,  then  clearing  up. 

(3)  Or  persisting  and  leaving  some  permanent  trouble  as  impaired 
memory,  partial  blindness  or  deafness,  insanity,  epilepsv. 


HEAT  SYNCOPE   AND   HEAT   STROKE  393 

It  appears  to  be  a  form  of  meningitis. 

The  temperature  rises  suddenly  as  a  rule,   104°,   107°,   110°  F. 

There  may  be  frequent  desires  to  micturate. 

PATHOLOGY. 

Post  mortem,   there  may  be  little  found. 

There  may  be  a  post-mortem  rise  of  temperature,  or  a  raised  tem- 
perature maintained  for  some  time  after  death.  When  the  temperature 
has  been  known  to  fall  after  death  it  has  never  been  known  to  rise 
again  after  any  disease. 

The  lungs  are  congested.  The  vessels  in  the  meninges  are  con- 
gested. There  may  be  minute  hemorrhages  in  the  brain  substance. 
There  is  a  coagulative  necrosis  of  the  nerve  cells. 

(B)  Indirect. 

This  is  much  the  same  as  the  direct  but  exposure  to  the  sun  is  not 
necessary.     It  may  come  on  at  night. 

There  may  be  prodromata. 

Sambon  savs  that  it  has  a  distinct  geographical  distribution,  and  is 
caused  by  some  microbic  agency. 

Newcomers  are  more  liable  to  it. 

Long  residence  produces  a  relative  immunity. 

The  predisposing  causes  are  as  before  mentioned. 

It  is  most  prevalent  in  the  hottest  season. 

It  may  become  epidemic  at  times. 

It  has  a  definitive  course,  peculiar  lesions,  tends  to  terminate  by 
crisis  and  thus  behaves  like  a  specific  fever. 

Some  authorities  affirm  that  this  is  the  same  as  the  direct  form. 

THE  MORTALITY  OF  HEAT  STROKE. 

Early  judicious  treatment  is  very  effective. 

The  mortality  is  15  per  cent,  to  20  per  cent. 

It  is  stated  that  among  the  English  troops  in  India  one  in  four  die. 

During  the  Great  War,  1,026  men  were  passing  some  hours  in  a 
train  in  India.     There  were  136  cases  of  heat  stroke  with  15  deaths. 

Overcrowding  was  blamed  chiefly. 

Sir  Victor  Horsley  died  from  heat  stroke  while  on  active  service 
in  Mesopotamia. 

DIAGNOSIS. 

Diagnose  from  A,  E,  I,  O,  U,  and  sometimes  D  and  T. 
A   Icoholic  poisoning. 
E  pileptic  conditions. 

/    ntracranial    causes   such    as    meningitis,    cerebral    haemorrhage, 
thrombosis,   embolism,    gummata,   and   all   tumours. 


394  DISEASES  OF  UNCERTAIN  ETIOLOGY 

O  pium  poisoning. 

U  raemic  conditions. 

D  iabetic  conditions. 

T  ropical  diseases,  malaria,  sleeping  sickness,  &c. 

TREATMENT. 

Remove  the  patient  to  a  cool  place  and  loosen  clothing. 

Application  of  cold  water  and  cold  sponging. 

Ice  is  essential  for  hyperpyrexia. 

Put  the  patient  upon  a  rubber  stretcher  covered  with  a  sheet  and 
the  head  raised,  a  sheet  also  covering  the  patient. 

Place  ice  on  sheet  for  two  minutes  and  put  the  patient  between 
blankets  in  bed. 

Give  tincture  of  digitalis,  30  minims. 

If  the  patient  is  plethoric,  bleed  from  the  median  basilic  vein. 

Cease  treatment  when  the  temperature  is  down  to  102*^,  103°  F.  in 
the  rectum. 

Later  apply  hot  bottles  and  stimulants. 

Avoid  strychnine  as  convulsions  are  not  uncommon. 

Artificial  respiration  may  be  necessary  for  an  hour  or  longer. 

Antipyretics  are  dangerous. 

Relapses  are  common. 

Salines  and  bromides  may  be  useful. 

Urge  total  abstinence. 

Blue  glasses  and  helmets  should  always  be  worn  afterwards. 

Spinal  pads  and  neck  shields  are  preventive  measures. 

SOME  UNCLASSIFIED  FEVERS. 

(1)   JAPANESE  RIYER  FEVER   (Tsutsugamushi  Disease). 
DEFINITION. 

An  acute  endemic  febrile  disorder  caused  by  the  bite  of  the  larval 
form  of  the  mite  Leptus  akamushi,  associated  with  a  small  local 
necrotic  area,  enlarged  proximal  glands,  and  an  exanthematous 
eruption. 

DISTRIBUTION. 

The  Island  of  Nippon  (Japan),  in  the  Akita  and  Xugata  districts. 

The  causative  mite  appears  in  the  areas  flooded  bv  rivers  a  few 
weeks  after  the  waters  have  subsided.  Because  of  them  the  districts 
have  been  almost  abandoned. 

iETIOLOGY. 

This  is  unknown. 

Bacterial,  protozoal  and  chemical  theories  have  been  advanced. 


SOME    UNCLASSIFIED    FEJ'ERS  395 

An  attack  does  not  confer  immunity. 

Poor  people  of  reduced  resistance  entering  the  infected  lands  from 
Julv  to  October  may  contract  the  disease. 

SYMPTOMATOLOGY. 

Incubation  is  four  to  ten  days. 

Prodromata,   nothing  definite,  sometimes  malaise  and  giddiness. 

Course.  It  lasts  about  fourteen  days.  Rigors,  frontal  headache, 
temperature  101°  to  103°  F. 

Tender  enlarged  lymphatic  glands  nearest  to  the  bite  of  the  mite ; 
a  vesicle  or  blackish  necrotic  patch  indicates  the  latter. 

Temperature  rises  to  105°  F.  The  necrotic  area  is  thrown  off 
leaving  a  circular  red  punched-out  ulcer. 

The  sixth  to  seventh  day  a  large  red  papular  (2  to  5  mm.)  eruption 
occurs  on  the  face  and  then  spreads  over  the  body  with  a  somewhat 
macular  appearance.     The  rash  does  not  itch. 

The  gums  may  become  spongy  and  bleed. 

Respirations  are  increased,   B.  S.  harsh,   rhonchi  all  over  chest. 

The  conjunctivae  are  injected.     There  is  lachrymation. 

Hyperaesthesia  is  common  and  is  present  all  over  the  body. 

Lysis  begins  about  the  fourteenth  day  and  lasts  about  one  week. 

In  bad  cases,  coma,  hvperpvrexia,  cardiac  failure  or  pulmonary 
oedema  ma}-  carrv  off  the  patient. 

MORTALITY. 

About  30  per  cent.  die.  It  increases  with  age.  i2'5  per  cent, 
during  the  first  ten  years  of  life  and  57  per  cent,  in  the  seventh  decade. 

TREATMENT. 

This  is  symptomatic. 

(2)    PIGMENTARY  FEVER    (Cobb). 

Occurs  in   Bengal  during  the  hottest  months. 

Sudden   onset;   the  temperature   rises   to    io3°-i04°  F.     Headache, 
nausea,  vomiting,  and  a  peculiar  pigmentation  of  the  nose  and  cheek. 
The  fever  lasts  eight  to  ten  da^'S.     Little  is  known  about  it. 

(3)    HYPERPYREXIAL  FEVER. 

Seen  on  the  West  Coast  of  Africa  and  Ceylon. 
Onset  like  malarial  fever  with  sweating,  but  no  parasites  are  seen. 
The  second  day  the  patient  feels  almost  normal. 
The   third   day  the  temperature  begins  to   rise  and   reaches  from 
i04°-io7°  F.,  at  which  it  tends  to  remain. 
Drue's  are  useless. 


396  DISEASES  OF  UNCERTAIN  ETIOLOGY 

Cold  baths  reduce  the  temperature  temporarily  during  the  first  six 
or  seven  days. 

The  temperature  then  rises  to  iio°  F.  about  the  eighth  day. 

Delirium  sets  in,  coma  and  death  in  50  per  cent,  of  cases. 

Others  recover.  The  temperature  remains  at  about  105°  F.  for 
three  weeks,  and  falls  to  normal  about  the  sixth  week. 

Little  is  known  about  the  aetiology,  &c. 

The  viscera,  blood  and  urine  appear  to  be  normal. 

(4)  DOUBLE  CONTINUED  FEVER. 

This  is  seen  in  China.  Onset  insidious.  Temperature  gradually 
rises  to  104°  F.,  remitting  three  degrees  daily;  pulse  slow,  tongue 
moist  and  red,  constipation.  After  ten  to  fifteen  days  the  temperature 
falls  to  normal  by  lysis. 

After  a  lapse  of  two  to  seven  days  the  fever  is  repeated  and  lasts 
about  ten  days.  The  anaemia  is  considerable.  Convalescence  is 
prolonged. 

The  mortality  is  low.     Quinine  is  useless. 

(5)   LOW  INTERMITTENT   NON-MALARIAL  FEVER. 

This  is  seen  in  India,  China,  Siam  and  Ceylon. 
The  onset  is  insidious,  or  it  may  follow  a  mild  form  of  influenza. 
The  fever  is  remittent  between  98*4°  and  102°  F. 
Chilliness  is  felt  daily  between  10  and  12  o'clock. 
The  eosinophilic  cells  are  increased  even  when  worms  are  absent. 
The  course  of  the  fever  is  long,  some  over  five  months. 
Nothing  else  abnormal   is  found.     The  patient  should  be  sent   to 
another  climate. 

(6)    NASHA   FEVER. 

It  is  seen  in  Bengal  from  April  to  August  annually. 

It  is  rarely  present  in  the  cold  weather. 

The  onset  is  sudden  M-ith  chill,  high  fever,  hyperemia,  swelling  of 
the  nasal  mucosas,  pains  in  head,  neck  and  shoulders. 

The  face  is  flushed,  the  pupils  contracted. 

There  is  a  papular  eruption,  some  bronchial  symptoms. 

The  fever  is  remittent  and  disappears  in  three  to  five  days,  when 
the  nasal  swelling  subsides.  Relapses  may  occur  between  the  first  and 
fourth  week  after  the  attack.  Some  may  be  severe,  terminating  in 
delirium,  coma  and  death. 

Give  saline  purgatives,  mild  diaphoretics,  spray  nose  with  iced 
water. 

Apply  tannin,  10  per  cent.,  and  cocaine  solution  to  the  nasal 
mucosae. 


SOME    UNCLASSIFIED    FEJ'ERS  397 

(7)   ARCHIBALD'S  FEVER. 
DEFINITION. 

An  Linclassilied  septicaemia  in  the  Anglo-Egyptian  Sudan  caused 
by  a  bacillus  of  the  B.  cloaca  group. 

SYMPTOMATOLOGY. 

The  temperature  rises  101^-103°  F.,  drowsiness,  sometimes  delirium, 
dry  furred  tongue,  sometimes  the  spleen  is  slightly  enlarged. 

The  temperature  falls  to  normal  in  about  one  week,  after  which  a 
long  remittent  fever  continues. 

Pneumonia,  abscesses,  femoral  thrombosis  may  set  in. 

Treatment  is  symptomatic. 

(8)   BACILLUS  ASIATICUS  FEVER. 

This  is  seen  in  Ceylon. 
It  is  caused  by  B.  asiaticus,  two  varieties. 
The  disease  is  a  septicaemia. 

There  is  a  long  low  remittent  fever,  sometimes  intermittent  with 
marlvcd  abdominal  pains,  but  no  diarrhoea. 

The  specific  bacillus  can  be  recovered  from  the  faeces. 
The  agglutination  test  can  be  used. 
Autogenous  vaccines  may  be  injected. 

(9)  THE  MACULAR  FEVER  OF  TUNISIA. 
DEFINITION. 

An  acute  febrile  disorder  characterized  by  a  macular  eruption  on 
the  abdomen,  palms  and  soles,  often  persisting  for  several  davs  after 
the  temperature  has  become  normal. 

SYMPTOMATOLOGY. 

The  onset  is  sudden,  rigors,  fever,  joint  pains,  injected  conjunctiva?, 
nausea,   vomiting,   constipation  and  insomnia. 

The  rash  comes  from  the  second  to  the  fourth  day,  red  spots  dis- 
tributed as  above. 

There  is  lymphocytosis,  35  per  cent. 

The  fever  lasts  two  weeks. 

The  rash  fades  without  desquamation.  Perhaps  this  fever  is 
related  to  typhus  fever. 

(10)    FIVE-DAY    FEVER    (VOLHYNIA    FEVER). 

The  findings  and  views  of  different  observers  are  very  conflicting 

The  causative  organism  is  unknown. 

Lice  have  been  blamed  as  the  carriers. 

The  course  is  mild,  the  prognosis  good,  and  complications  are  rare. 

The  peculiar  features  are  its  periodicity  and  an  increase  of  the  leuco- 


398  DISEASES  OF  UNCERTAIN  ETIOLOGY 

cytes  as  the  fever  subsides.  Bone  cells  are  seen  in  the  blood.  A  mild 
eruption  is  seen  in  some  cases. 

Quinine  and  salvarsan  are  said  to  be  useless. 

Collargol  is  said  to  act  as  a  specific  when  given,  lo  c.c.  of  a  i  per 
cent,  solution  three  doses  intravenously.   This  is  said  to  cure  (Heyden). 

(11)   RAT-BITE  FEVER. 
DEFINITION. 

An  acute  infectious  disease,  probably  caused  by  spirochaetes 
characterized  by  a  local  ulcer,  followed  by  constitutional  disturbances 
of  pyrexia,  eruption  and  body  pains. 

DISTRIBUTION. 

It  is  found  in  Japan,  England,  the  United  States,  and  Italy. 

iETIOLOGY. 

Futaki  discovered  spirochaetes  in  the  blood  and  tissues  of  patients 
in   1916.     The  organism  was  pathogenic  to  guinea-pigs. 

Spirochaetes  have  been  found  in  the  suprarenals  and  kidneys  of 
people  dead  of  the  disease. 

At  first  the  organism  circulates  in  the  blood  ;  then,  when  immune 
bodies  are  formed,  they  are  found  in  the  kidneys.  The  antibodies 
thus  formed  act  upon  the  causative  spirochaetes,  producing  degenerate 
forms.  In  this  particular  the  disease  simulates  Spirochetosis  ictero- 
hsemorrhagica. 

The  etiology  seems  now  to  be  established,  so  that  upon  con- 
firmation of  the  above  findings  it  will  be  necessary  to  include  this 
disease  in  another  section  of  this  work. 

SYMPTOMATOLOGY. 

The  incubation  is  one  to  three  weeks. 

The  onset  is  sudden.  An  ulcer  forms  seven  to  fifteen  davs  later 
at  the  site  of  the  bite  which  had  previouslv  healed.  The  proximal 
glands  are  swollen. 

There  is  a  papular  purple  eruption  on  the  body  in  some  cases,  pains 
about  the  joints  and  muscles,  pyrexia  to  104°  F.,  and  sometimes 
delirium. 

After  a  few  days  the  fever  abates  and  the  patient  feels  better;  then 
it  recurs.     These  relapses  are  rather  characteristic  of  the  disease. 

Each  attack  leaves  the  patient  somewhat  better,  but  it  may  be 
months  or  years  before  the  disease  has  run  its  course. 

The  prognosis  is  good  and  complications  rare. 

The  mortality  is  about  ip'5  per  cent. 

TREATMENT. 

Arsenical  treatment  is  the  rule — as  for  Relapsing  fever. 


SOME    UNCLASSIFIED    FEVERS 


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DISEASES  OF  UNCERTAIN  .ETIOLOGY 


(12)  TRENCH  FEVER. 
DEFINITION. 

It   is  a   specific   infectious   disease   caused  by  a   resistant   filterable 
virus  in  the  blood  plasma,  transmitted  b\-  lice. 

DISTRIBUTION. 

Flanders,   Mesopotamia,  Salonica,  and  Italy. 


SEPT 


OCT. 


DATE 

18 

19 

20 

2! 

22 

23 

24- 

25 

26 

27 

28  29  3 

0    1        2 

3 

F° 
1  0  3° 

102° 

10  f° 

1  0  0° 

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9  8° 

9  7° 

M  e: 

M  E 

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Trench  fever. 

^ETIOLOGY. 

The  causative  organism  is  present  in  the  blood  plasma,  and  is 
transmitted  naturally  by  the  louse. 

The  blood  is  always  infective  in  the  earlv  stages. 

The  organism  is  not  filterable.     Spirochetes  have  been  blamed. 

The  virus  has  been  recovered  from  the  urine  and  from  mixed 
sputum  and  saliva,  but  not  from  the  faeces. 

SYMPTOMATOLOGY. 

The  incubation  period  is  fourteen  to  thirtv  davs,  or  in  some  cases 
shorter. 

The  onset  is  sudden,  with  headache,  dizziness,  pains  in  the  legs 
(shin    pains),    back,    and   behind    the   eyeballs,    pyrexia    i03°-i04°    F., 


THE    EXANTHEMATA  401 

which  becomes  relapsing  in  one-half  of  the  cases,  erythematous  spots 
in  70  to  80  per  cent,  of  cases,  enlargement  of  the  spleen,  and  slight 
albuminuria. 

The  fever  may  be  but  one  sharp  rise,  or  it  may  oscillate  for  four  to 
six  days,  or  relapse  over  six  to  seven  weeks,  wdth  intervals  of  five  to 
seven  days.  Some  patients  have  had  some  fever  for  periods  of  forty 
to  sixty  days  with  only  slight  remissions. 

There  are  three  to  five,  or  even  seven  relapses. 

RecoverA'  is  the  rule. 

TREATMENT. 

This  is  symptomatic.  Arsenical  preparations  as  for  Relapsing 
fever  can  be  tried. 

All  lice  should  be  destroyed  and  clothing  sterilized. 

Sputum  cups  and  special  urine  bottles  should  be  reserved  for 
patients  and  their  contents  sterilized. 

THE  EXANTHEMATA. 

As  the  majority  of  these  are  described  in  general  text-books  of 
medicine  a  few  remarks  only  will  be  necessary. 

Scarlet  fever  may  be  introduced  into  the  tropics,  but  does  not  spread 
there. 

Measles  is  endemic  in  most  tropical  countries  and  may  give  rise  to 
severe  epidemics. 

Chicken-pox  is  usually  mild,  but  it  may  be  severe.  It  more  often 
attacks  adults  in  the  tropics.  It  is  common  in  India  from  February 
to  March. 

Variola  has  long  been  present  in  India  and  Africa.  It  was  perhaps 
introduced  into  China  from  India  about  the  third  century  B.C. 

An  African  mummy  has  been  found  with  a  cutaneous  eruption 
belonging  probably  to  the  twenty-eighth  dynasty  (1200-1100  B.C.). 
How  it  came  to  Africa  and  India  is  not  known.  It  is  common  all  over 
the  tropics  to-day. 

"  Alastrim." — Perhaps  this  is  a  mild  variola  that  does  not  breed 
true. 

This  acute  specific  fever  resembles  a  mild  form  of  variola. 
It  is  widely  distributed  in  the  tropics. 
Jenner's  vaccination  is  generally  held  to  be  protective. 
It  differs  from  chicken-pox  because  of — 

(i)  Confluence  of  the  vesicles  in  certain  cases. 

(2)  Its  frequency  amongst  adults. 

(3)  Partial  protection  by  Jenner's  vaccine. 


402  DISEASES  OF  UNCERTAIN  ETIOLOGY 

It  differs  from  typical  variola  because  of — 
(i)  Its  low  mortality,   i  to  2  per  cent. 


"Varioloid  varicella,"  Trinidad.     Froia  a  photo  by  Dr.   Scheult. 

(2)  It  is  less  severe  in  children  than  in  adults;  it  is  often  found 
amongst  babies. 

(3)  There  is  no  secondary  fever  in  children. 

(4)  The  disease  can  occur  after  recent  successful  vaccination. 

(5)  Vaccination    can    be    successful   shortly    after   an    attack    of 
alastrim. 


THE    EXANTHEMATA  403 

(6)  Some  assert  that  small-pox  does  not  render  immunity  from 
alastrim. 
The    onset    is    sudden,    with    severe    pains,    high    fever,    vomiting, 
sometimes  delirium.     The  rash  appears  on  the  third  day,  the  tempera- 
ture is  reduced  and  the  symptoms  disappear,  and  the  patient  feels  well 
again. 

Secondary  fever  is  very  rare,  about  the  eighth  day  when  present. 
Papules    become   pustules   and  scales.     These    fall    off   with   some 
pigmentation,  but  very  little  permanent  scarring. 

Yesicuiar  Fever  begins  like  chicken-pox  and  ends  like  small-pox. 

The  symptoms  are  in  accordance  with  these  two  diseases. 

The  diagnosis  is  not  easy,  but  the  important  points  to  note  are  :  — 

There  is  no  true  pustulation  with  scarring  as  in  small-pox. 

And  Jenner's  vaccination  is  successful  during  convalescence. 

In  chicken-pox  the  vesicles  are  larger  and  leave  crusts. 

In  alastrim  the  eruption  is  often  confluent  and  pustular. 
The  prognosis  is  good. 

Papular  Fever — This  resembles  measles,  but  it  has  no  catarrhal 
symptoms. 

The  onset  is  insidious. 

The  prodromata  are  malaise,  depression,  rheumatoid  pains  in  back. 

Course. — The  rash  appears  on  the  third  or  fourth  day  suddenly  all 
over  the  bodv,  morbiliform,  bright  red,  pin-head  papules  and  red 
macuUe. 

The  face  is  not  much  affected. 

There  are  papules  in  the  mouth. 

A  slight  fever  lasts  one  to  two  days. 

There  is  no  enlargement  of  glands. 

The  eruption  lasts  two  to  five  days.  There  is  no  desquamation, 
and  there  are  no  marks  left.     The  rash  itches. 

Aspirin  relieves  the  pains  and  calamine  lotion  the  itching. 

HsBmorrhagic  Febrile  Gastro-enteritis  of  Children. 

It  is  seen  in  Guadeloupe. 
It  somewhat  resembles  yellow  fever. 

The  onset  is  sudden  with  vomiting,  followed  by  febrile  biliousness. 
There  is  a  remittent  fever,  slight  icterus,  obstinate  constipation,  and 
later,  black  vomit. 

After  two  to  five  davs,  improvement  sets  in  or  the  child  may  die. 

Convalescence  is  prolonged. 

The  prognosis  is  grave. 

The  treatment  is  svmptomatic. 


404  DISEASES  OF  UNCERTAIN  ETIOLOGY 

DISEASES   OF    UNKNOWN    ^.TIOLOGY   AFFECTING   THE 

RESPIRATORY  SYSTEM. 

(1)   TROPICAL  HAY  FEVER    (Rhinitis  spastica  vasomotoria). 

Adults  are  attacked.  There  are  violent  fits  of  sneezing,  lasting 
from  two  minutes  to  two  hours.     There  is  an  excess  of  nasal  secretion. 

Lachrymation,   conjunctivae  injected,   eyelids  swollen. 

These  attacks  may  recur  the  same  day  or  over  several  weeks. 

There  may  be  accompanying  asthmatical  symptoms. 

The  mucous  membrane  over  the  turbinate  bones  becomes  swollen 
and  may  cause  nasal  obstruction. 

A  spray  of  cocaine,  i  per  cent.,  and  adrenalin  locallv  is  useful. 

Atropine  and  strychnine  pills  may  be  tried. 

A  clTange  of  climate  may  clear  up  the  malady. 

(2)    GANGOSA    (Rhino-pharyngitis   mutilans). 
DEFINITION. 

An  ulcerative  condition  affecting  the  palate,  nose,  pharynx,  larynx 
and  skin,  destroying  cartilage  and  bone,  thus  producing  permanent 
deformity. 

DISTRIBUTION. 

It  appears  to  be  endemic  in  the  Batanes  Islands,  where  some  hold 
it  to  be  the  early  stage  of  leprosy. 

It  is  also  found  in  the  Ladrone  Islands,  Guam,  Caroline  Islands, 
Fiji,  Murray  Island,  Panama,  British  Guiana,  Ceylon,  Nevis, 
Dominica  and  Italy. 

Dr.  Anton  claims  that  it  is  a  blastomycosis  due  to  a  specific  parasite, 
the  Cryptococcus  mutilans.     This  requires  confirmation. 

SYMPTOMATOLOGY. 

A  sore  throat  is  complained  of,  caused  by  a  nodule  on  the  palate 
or  at  the  back  of  the  pharynx,  or  on  the  posterior  pillar  of  the  fauces. 
This  becomes  a  superficial  ulcer  covered  by  a  greyish  slough. 

This  ulcer  spreads,  destroying  the  adjacent  tissue,  soft  and  hard 
alike,  so  that  in  time  the  skin  falls  in  allowing  the  nasal  and  buccal 
cavities  to  form  one  aperture. 

It  may  then  afifect  the  face  without  or  the  larynx  within. 

Vision  may  be  destroyed.     The  odour  given  ofif  is  most  offensive . 

Ulcers  may  appear  on  other  parts  of  the  skin  which  is  uncovered 
by  clothing. 

Ugly  deformities  are  caused  by  the  scarring  and  contraction. 

A  chronic  osteitis  may  set  in  simulating  that  of  syphilis. 


SOME  NERJ'OUS  DISTURBANCES  IN  THE  TROPICS      405 

It  mav  go  on  from  ten  to  thirty-five  years,  progressively  or  inter- 
mittently. 

Wassermann's  reaction  is  always  positive. 

As  a  rule  the  o-eneral  health  is  little  affected. 

It  is  rarelv  fatal^  and  all  tend  to  recover  ultimately. 

DIAGNOSIS. 

There  are  neither  signs  nor  symptoms  of  s}'pliilis  (Johnson  does 
not  agree). 

The  spirocha?te  cannot  be  found  and  iodides  are  useless. 

There  are  no  leprosy  nodules  nor  anesthetic  patches. 

Hansen's  bacillus  has  not  been  found. 

Its  histological  characters  are  not  those  of  epithelioma. 

There  are  no  metastases  and  its  course  is  protracted. 

Tuberculosis  is  excluded  by  the  absence  of  Koch's  bacillus  and 
other  symptoms. 

Guinea-pigs  cannot  be  inoculated  successfully. 

TREATMENT. 

Nothing  will  stop  its  onward  course. 

Application  of  iodine  tincture  or  the  actual  cautery  can  be  tried. 
Wash  the  foul  ulcers  with  potassium  permanganate  or  peroxide  of 
hydrogen. 

Segregation  is  essential  for  stamping  out  the  disease. 

SOME  NERVOUS  DISTURBANCES  IN  THE  TROPICS. 
(1)    TROPICAL   NEURASTHENIA. 

This  is  a  condition  somewhat  common  in  white  people,  and  the 
better  class  coloured  people  residing  in  the  tropics,  especially  where 
there  is  a  moist  warm  atmosphere. 

There  are  many  predisposing  causes,  such  as  malarial  fever,  or 
other  illness,  overwork  and  alcoholism. 

Perhaps  30  per  cent,  to  50  per  cent,  of  white  residents  become  semi- 
invalids  from  this  malady. 

Palpitation  with  heat  flushes  is  usually  present.  Phobia,  especially 
with  regard  to  diseases,  is  a  common  feature.  Sleeplessness  and 
irritability  are  common. 

The  condition  is  the  cause  of  many  clerical  errors  and  inaccuracies 
which  lead  to  numerous  petty  worries  and  manifestations  of  bad 
temper. 

The  patient  should  have  a  change  of  work  and  climate. 

Neither  sedatives  nor  tonics  have  been  much  use  in  the  writer's 
experience. 

26 


4o6  DISEASES  OF  UNCERTAIN  ETIOLOGY 

(2)    ENDEMIC   PARALYTIC   VERTIGO. 

This  is  seen  in  France,  Switzerland,  Shiivoku,  Japan. 

The  aetiology  is  unknown. 

An  attack  begins  with  the  blurring  of  objects,  ptosis,  paralysis  of 
the  internal  rectus  causing  diplopia,  photophobia,  affection  of  colour 
vision,  hyper^eniia  of  the  optic  disc. 

vSpeech  is  disturbed,  mastication  difficult  through  paresis,  and  later 
paralysis  of  the  muscles  that  operate  those  functions. 

The  head  falls  forward  as  the  neck  and  shoulder  muscles  are 
affected.     The  posture  may  be  stooping. 

Weakness  of  arms,  hands  and  legs  is  not  uncommonly  seen. 

The  attack  usuallv  lasts  ten  to  fifteen  minutes. 

Between  attacks  the  patient  may  be  perfectly  well. 

The  disease  is  never  fatal. 

Iodides  and  arsenic  should  be  given. 

Remove  the  patient  to  a  healthy  climate  and  district. 

(3)  ENDEMIC  PERIPHERAL  NEURITIS. 

This  is  seen  upon  the  Central  African  plateau,  5,000  to  6,000  feet 
high. 

It  is  said  to  affect  3  per  cent,  to  5  per  cent,  of  the  Bantu  people. 

There  are  shooting  or  pricking  pains  in  the  forearms  and  legs., 
accompanied  by  numbness,  with  an  erythematous  rash  and  local  swell- 
ing of  the  affected  area. 

Cold  and  damp  increase  the  symptoms. 

Heat  and  dryness  diminish  them. 

The  gait  is  peculiar,  the  patient  having  the  appearance  of  walking 
upon  his  toes  and  heels. 

The  whole  body  may  be  affected. 

The  disease  may  spontaneously  clear  up  or  it  may  last  for  years. 

(i)  LATAH. 

This  is  seen  in  the  Malay  Peninsula,  Java,  Sumatra,  Siam, 
Burmah,   Philippines,   Siberia  and  North   America. 

ETIOLOGY  (Abraham). 

Auditory,  an  unexpected  noise  behind  a  person. 
Visual,  some  unlooked-for  movement. 
Tactile,  an  unexpected  sudden  touch. 

SYMPTOMATOLOGY. 

The  action  seen,  noise  heard  or  words  uttered  may  be  repeated, 
with  the  addition  often  of  foul  language. 


ENDEMIC    FUNICU LITIS  407 

The  patienl  is  conscious,  bui  cannot  apparently  control  his  actions. 
The  hand  spontaneously  rises  to  the  head. 

There  is  a  loss  of  memory  of  what  has  taken  place. 

The  actions  may  be  impulsive  or  mimetic. 

It  is  not  unlike  the  "  jumpers  "  or  "  jerks  "  seen  in  Europe  during 
the  Middle  Ages. 

It  is  sometimes  present  during  religious  revivals  of  to-day. 

It  has  a  medico-legal  aspect  of  considerable  importance. 

These  subjects  are  often  teased,   irritated  and  made  worse. 

Auto  suggestion  can  be  tried. 

Determination  on  the  part  of  the  patient  is  essential. 

(5)   AMOK  (  =  an   impulse  to  murder). 

This  is  a  term  applied  to  a  condition,  partly  physical,  partly 
psychical,  following  a  period  of  depression. 

They  are  capable  of  self-violence  and  of  wounding  and  killing 
others. 

Memory  fails  them  as  to  what  they  have  done. 

The  attack  is  followed  by  a  condition  of  stupor. 

It  is  seen  in  Malaysia,  Trinidad,  India  and  Liberia. 

The  exciting  causes  are  excessive  smoking  of  Cannabis  indica,  or 
opium,  or  some  strong  emotion,  such  as  anger,  fear  or  sorrow. 

After  this  the  patient  broods  over  his  wrongs  for  davs  or  w'eeks, 
then  complains  of  the  appearance  of  devils,  and  goes  forth  to  kill  them 
with  his  flame-shaped  knife  or  his  gun. 

The  attack  lasts  but  a  short  time. 

ENDEMIC   FUNICULITIS. 
DEFINITION. 

An  acute  specific  suppurative  inflammation  of  the  spermatic  cord 
of  uncertain  aetiology.     The  theories  of  causation  are  legion. 

DISTRIBUTION. 

It  is  seen  in  Southern   India,   Egypt,  West  Indies,  Ceylon. 

PATHOLOGY. 

The  whole  cord  is  wholly  inflamed,  infiltrated  and  swollen. 

It  may  be  3^  inches  in  circumference. 

On  incising  it  transversely,  yellow  pus  exudes  from  the  veins  of 
the  pampiniform  plexus  and  the  vas  deferens. 

The  inflammation  also  attacks  the  epididymis. 

There  is  usually  some  oedema  and  a  little  clear  fluid  in  the  tunica 
vaginalis. 


4o8  DISEASES  Of  UNCERTAIN  /ETIOLOGY 

The  microscope  shows  the  veins  of  the  pampiniform  plexus  dilated 
with  pus  cells  and  thrombi ;  the  coats  of  the  veins  and  the  vas  deferens 
are  infiltrated  by  small  cells. 

SYMPTOMATOLOGY. 

The  onset  is  sudden.  The  patient  after  a  day  of  hard  work  feels 
tired,  takes  a  bath,  and  has  a  shivering  fit  and  a  rise  of  temperature. 
There  may  be  vomiting. 

There  is  pain  along  the  cord  and  epididymis. 

The  condition  becomes  rapidly  worse. 

On  the  third  dav  there  mav  be  continuous  vomiting  and  some 
hiccough. 

The  temperature  is  about  102°  F.,  the  pulse  small  and  rapid. 

The  cord  is  swollen,  hard  and  tender. 

The  skin  over  it  is  normal. 

The  condition  is  usually  unilateral. 

There  are  no  signs  of  gonorrhoea  or  trauma. 

If  left,  a  septic^emic  condition  sets  in,  the  skin  becomes  jaundiced, 
cutaneous  hemorrhages,  the  fever  rises  and  the  pulse  cjuickens,  the 
hiccough  is  worse,  and  death  follows  in  a  few  days. 

Spontaneous  recovery  is  the  exception. 

TREATMENT. 

The  only  effective  treatment  is  prompt  surgical  interference. 

The  inflamed  cord  should  be  excised  as  high  as  affected. 

The  testis  loses  its  generative  function  in  all  but  the  mildest  cases. 


EPIDEMIC  GANGREXOl\S  RECTITIS.     (Ackers.) 
DEFINITION. 

A  very  rapidly  fatal  and  spreading  phagedasnic  disease  about  the 
anus  and  the  lower  part  of  the  colon,  confined  to  the  natives  of  the 
northern  provinces  of  South  America,  Fiji  and  other  islands  of  the 
South  Pacific. 

It  occurs  amongst  the  children  of  poor  natives  and  also  in  animals. 

SYMPTOMATOLOGY. 

There  is  anal  itching,  tendency  to  frequent  defalcation,  inflam- 
mation of  the  rectal  mucous  membrane,  the  latter  developing  in  about 
three  days,  followed  by  acute  dysenteric  symptoms,  mucus,  blood, 
sometimes  bile  with  much  tenesmus. 

There  is  some  fever,  thirst  and  anorexia. 

A  semi-liquid,  slimy,  foetid,  blood-stained,  greenish  stool  comes 
awav. 


INFANTILE    BILIARY    CIRRHOSIS  409 

All  food  is  refused.     The  thirst  becomes  intense. 
Prolapse   is  common.     Gangrene  sets  in,   spreads  rapidly,   and    is 
fatal. 

TREATMENT. 

As  practised  by  the  natives. 
For  animals. 

An  enema  of  strong-  lemon-juice  mixed  with  diluted  white  rum 

(aguadiente)  thrice  daily. 

Dust  tlie  anus  with  wood  ashes. 

An  oil  purgative  is  given. 

This  appears  to  be  successful  in  early  cases. 
For  children. 

Give  an  enema  of  juice  from  the  stalks  and  leaves  of  Spigelia 

anthelmentica  (Pasote). 

A  decoction  of  the  same  is  given  bv  mouth  thrice  dailv. 
(This  mixture  is  also  given  as  an  anthelmintic.) 

A   portion    of   roasled    lemon    inserted    into  the    rectimi    once   or 

twice  daily. 
It  is  said  to  be  caused  b}'  children  chewing  the  green  tender  stalks 
of  unripe  maize. 

INFANTILE   BILIARY   CIRRHOSIS. 

This  is  a  rapidly  fatal  disease  attacking  young  native  children  in 
Calcutta  and  some  other  large  Indian  towns. 

iETIOLOGY. 

Children  are  attacked  in  their  first  year  during  dentition  as  a  rule. 
They  are  rarely  attacked  from  the  first  to  the  third  year. 

Hindoo  children  in  Calcutta  had  a  mortality  of  1,616  (1891-1893), 
and  Mahommedan  children  in  the  same  citv  had  80  dead  during  the 
same  period. 

The  children  of  the  rich  suffer  more  than  those  of  the  poor. 

It  tends  to  run  in  families,  and  attacks  them  as  the  young  are  born. 
Nearly  if  not  all  of  those  attacked  die. 

Alcohol,  syphilis,  and  malaria  have  been  excluded. 

The  cause  is  unknown. 

Some  suggest  that  it  is  a  variety  of  kala-azar. 

SYMPTOMATOLOGY. 

The  onset  is  insidious.     The  liver  enlarges  even  to  the  umbilicus. 

There  is  nausea,  sometimes  vomiting,  sallow  skin,  constipation, 
irritability  and  anorexia.  Low  fever  sets  in  with  jaundice,  pale  stools 
and  dark  urine. 


410  DISEASES  OF  UNCERTAIN  ETIOLOGY 

There  mav  be  oedema  of  the  feet  and  hands  with  ascites. 
Death  from  rholccmia  ensues  in  a  few  weeks  to  a  few  months. 

PATHOLOGY. 

The  bihary  cirrhosis  seems  to  be  the  resuh  of  some  gastric  irritant 
acting  upon  the  hver  cells.  The  cells  at  first  become  degenerate,  then 
the  intercellular  connective  tissue  is  increased,  follow^ed  by  that  of  the 
portal  sheaths. 

There  is  a  marked  attempt  to  form  new  bile  ducts  between  the 
hepatic  cells  (Gibbons). 

TREATMENT. 

Early  removal  from  the  district  has  been  suggested. 
A  change  of  wet  nurse  and  infant  foods  could  be  tried. 

GOITRE. 

In  the  Tropics  this  condition  does  not  appear  to  be  associated  with 
any  geographical  or  geological  condition. 

Many  authorities  believe  it  to  be  of  parasitic  origin,  and  suspect  an 
amoeba  which  is  ingested  with  water. 

A  new-comer  to  an  endemic  district  notices  that  after  a  few  weeks 
his  neck  begins  to  swell  gradually.  At  times  it  may  be  stationary,  at 
others  progressive  until  a  permanent  hypertrophy  results. 

The  whole  thyroid  gland  is  usually  affected. 

Later  it  may  undergo  cystic  or  adenomatous  changes. 

Removal  to  another  non-endemic  district  will  cause  it  to  diminish 
in  size  and  to  clear  up  in  earlv  cases. 

Salol  and  thymol  arc  sometimes  given. 

CLIMATIC   BUBO. 
DEFINITION. 

A  painful  gradual  enlargement  of  the  inguinal  Ivmphatic  glands 
with  fever  of  uncertain  as^^tiology. 

DISTRIBUTION. 

The  East  Coast  of  Africa,  West  Indies,  Straits  Settlements,  China, 
Madagascar,   Chille,   Uganda,  and  many  other  places. 

iETIOLOGY. 

Hewlett  has  isolated  a  bacillus  not  decolorized  by  Gram  and  not 
unlike  the  B.  pestis. 

Cantlie  believes  it  to  be  a  form  of  attenuated  plague,  pestis  minor, 
Hewlitt's  isolation  supporting  it. 

Others  hold  that  the  disease  is  a  distinct  entity. 


GOUNDOU  411 

PATHOLOGY. 

The  gland  capsule  is  thickened. 

The  lymphocytes  are  in  great  excess. 

Ha^morrhagic  foci  may  be  seen. 

There  are  numerous  typical  plasma  cells  that  are  absent  in  plague. 

The  retractile  cells  of  Recklinghausen  are  absent,  but  present  in 
plague. 

SYMPTOMATOLOGY. 

The  onset  is  gradual. 

Several  days  of  malaise  precede  slight  fever  and  pain  in  one  or 
other  or  both  inguinal  glands. 

The  inguinal  glands  are  enlarged,  hard  and  tender. 

These  may  become  as  large  as  a  goose's  ^gg- 

A.S  a  rule  they  do  not  suppurate. 

Lymphangitis  is  absent. 

Aspiration  yields  a  little  sterile  fluid,  but  no  pus. 

The  fever  is  low  and  irregular,  about  102°  F. 

The  disease  may  last  a  few  days,  weeks,  or  months. 

The  general  health  is  good. 

TREATMENT. 

This    is   symptomatic.     Rest    in    bed.     Lead    lotion,    ichthyol    and 
belladonna  ointment,  and  mild  aperients. 
Incise  when  sepsis  is  present. 

GOUNDOU. 

This  condition  is  a  bony,  bilateral,  symmetrical  swelling  situated 
on  either  side  of  the  root  of  the  nose.     It  is  rarely  unilateral. 

Some  observers  assert  that  it  is  a  general  condition  that  affects  the 
other  bones  of  the  skeleton  also. 

It  occurs  in  young  people  of  native  races  and  is  commonest  in 
the  West  Indies.  The  writer  has  seen  it  in  the  Kasai  basin,  Central 
Africa  and  on  the  Gold  Coast. 

The  condition  has  been  reported  in  an  European  (Cantlie). 

The  aetiology  is  unknown. 

PATHOLOGY. 

Outside  the  bony  swelling  is  a  thin  layer  of  compact  bone,  all  the 
remaining  mass  being  spongy  bone. 

The  covering  periosteum  strips  off  easily  and  shows  no  sign  of 
inflammation. 

The  growth  may  be  attached  to  the  nasal  bone,  the  nasal  process 
of  the  superior  maxilla,  or  to  the  maxilla  itself. 

The  skin  over  the  tumour  is  always  freely  movable. 


412  DISEASES  OF  UNCERTAIN  .ETIOLOGY 

SYMPTOMATOLOGY. 

Gradual  onset,  pain  in  the  nose,  bloody  discharge  lasting  six  to 
eight  months.  As  this  disappears  a  swelling  appears  and  increases 
in  size. 

The  vision  may  be  interfered  \vith. 
'      The  deformity  is  sometimes  hideous  in  the  extreme. 

There  mav  be  polvpoid-like  excrescences  protruding  from  the  nasal 
mucous  membrane. 

The  growth  ma}-  stop  at  any  time. 

TREATMENT. 

Surgical  removal  is  easy  and  effective. 
Other  treatment  is  symptomatic. 

BIG  HEEL. 

This  is  a  condition  seen  on  the  Gold  Coast  and  Formosa. 

The  aetiology  is  obscure. 

The  attacks  come  in  the  wet  season  with  sudden  onset  and  fever. 

There  is  great  tenderness  over  the  os  calcis  so  as  to  prevent  walking 
or  sleeping. 

In  three  to  seven  days  tlie  bone  enlarges  and  increases  progressively 
for  two  weeks  or  so,  during  which  time  the  pain  becomes  less  and  the 
fever  disappears. 

After  a  month  the  bone  ceases  to  grow  and  remains  like  this  for 
one  or  two  months,  when  the  patient  is  able  to  M'alk  with  some  degree 
of  comfort. 

The  growth  then  gradually  diminishes,  but  never  wholly  disappears. 

It  usually  affects  both  sides. 

The  ankle-joint  is  never  affected,  and  the  tarsal  bones  but  seldom. 

The  bone  should  be  trephined  or  gouged  down  to  afford  relief. 

AINHUM  (  =  to  saw  or  to  cut). 
DEFINITION. 

A  chronic  dystrophy  of  the  fifth  (rarel}-  other)  toes  in  native  races, 
characterized  by  the  formation  of  a  furrow  at  the  digito-plantar  fold, 
which  extends  and  deepens  until  the  toe  is  severed. 

It  is  seen  in  man}'  parts  of  the  Tropics. 

PATHOLOGY. 

There  is  irritation  of  the  cutaneous  epithelium  causing  an  internal 
proliferation,  extending  to  the  cutis,  injuring  the  vasomotor  nerves, 
causing  spasm  of  the  vessels,  endarteritis  obliterans,  fibrosis  of  the 
cutis  and  rarefying  osteitis  which  separates  tlie  digit. 


CHAP  PA  413 

No  organisms  can  be  found. 
(       The   source  of  the  irritation:    why   this   pariicular  spot   should   be 
cliosen,  and  why  a  fibrotic  ring  is  caused,  has  not  yet  been  made  clear. 

SYMPTOMATOLOGY. 

There  is  no  general  disturbance. 

It  begins  on  the  inner  side  of  the  digito-plantar  furrow. 

An  ulcer  may  form  that  causes  pain. 

The  condition  may  last  two  to  fifteen  years  until  the  toe  is  severed. 

In  10  per  cent,  of  cases  the  fourth  toe  is  affected. 

TREATMENT. 

No  known  treatment  is  of  any  avail. 

Some  divide  the  fibriotic  ring  early  so  as  to  save  the  toe,  but  the 
condition  usually  progresses. 

CHAPPA. 

This  is  seen  in  Lagos. 

There  are  severe  pains  in  the  muscles  and  the  joints  of  the 
■extremities. 

After  a  few  months  the  pain  increases  and  the  joints  swell. 

Nodules,  subcutaneous,  the  size  of  a  goose  Qgg  appear  in  different 
parts  of  the  body.  The  skin  over  them  ulcerates,  later  exposing  a  fatty 
base.     There  may  be  one  or  many  nodules. 

When  ulcerating  thev  ma}'  coalesce. 

Some  of  the  nodules  are  absorbed  without  ulceration. 

The  ulcers  may  last  for  years. 

The  joints  may  become  permanenll\-  disorganized  and  the  bones 
affected. 

It  may  be  a  tertiary  phase  of  yaws  (Manson).  Mercury  and 
iodides  are  useless. 

Scraping  and  antiseptics  are  good  measures. 

Neosalvarsan  could  be  tried. 


PONOS  (  =  pain). 

This  disease,  affecting  young  children  of  Spezzia  and  Hydra  in  the 
Grecian  Achipelago,  resembles  infantile  biliary  cirrhosis  of  Indian 
towns  in  that — 

It  is  confined  to  very  young  children. 

It  is  endemic  in   particular  districts. 

It  tends  to  run  in  families. 

It  is  invariablv  associated  with  the  disease  of  an  abdominal  viscus. 


414  DISEASES  OF  UNCERTAIN  ETIOLOGY 

SYMPTOMATOLOGY. 

It  affects  children  of  the  rich  and  poor  alike. 

The  onset  is  rather  sudden  in  the  first  year  of  life. 

Sallow  tint  of  skin  and  irregular  fever  are  present. 

The  spleen  enlarges  much  and  is  tender,  hence  the  name  "  ponos  " 
=  pain. 

Prostration  is  marked  and  emaciation  progressive. 

Late  in  the  disease  oedema  and  ascites  set  in. 

Hcemorrhages  from  the  gums  and  from  other  organs  are  not 
uncommon. 

Bronchitis,  pneumonia,  dysentery,  peritonitis  and  meningitis  are 
complications  to  be  looked  for. 

The  disease  lasts  from  two  months  to  two  years. 

A  pronounced  leucopenia  has  been  found. 

Some  suggest  because  of  this  that  it  may  be  of  protozoal  origin, 
related  to  kala-azar. 

TREATMENT. 

Nothing  specific  is  known. 

TROPICAL    LIVER. 

A  condition  of  hepatic  congestion  brought  about  during  the  first 
two  years'  residence  of  Europeans  in  the  Tropics. 

Chills,  changes  and  excesses  of  food  and  drink  cause  hypera^mia 
of  the  liver,  congestion,  blood  stasis  and  diminution  of  the  function 
of  that  organ. 

SYMPTOMATOLOGY. 

There  is  frontal  headache,  malaise,  nausea,  dyspepsia,  constipation 
and  pale-coloured  stools. 

The  liver  is  slightly  enlarged  and  tender,  slight  icterus,  diminished 
urine,  irritability,  slight  fever  to  ioo°  F. 

TREATMENT. 
Rest  in  bed  in  acute  cases. 
Calomel,  2  grains,  followed  by  saline  purges. 
Hot  fomentations  to  liver  region  are  good. 

Bland  diet,  no  alcohol  or  spiced  foods,  moderate  exercise,  avoid 
chills. 

The  following  mixture  has  been   found   useful  :  — 

H     Ammon.  carb.  ...         ...         grains     2-5 

Sod.  bicarb.      ...         ...         ...         ...         ...         ,,  20 

Citr  c  acid        „  20 

One  ounce  thrice  daily. 


BOOMERANG    LEG  415 

BOOMERANG   LEG. 

This  is  a  bowing  forwards  of  the  bones  of  the  legs  occurring  in 
young  aduhs  during  the  period  of  gro^\l]l.     It  is  of  uni^nown  causation. 

DISTRIBUTION. 

It  occurs  among  the  natives  of  Western  Australia,  Northern 
Territory,  North  Queensland,  Torres  Straits  and  British  New  Guinea. 

AETIOLOGY. 

The  post-mortem  appearance  suggests  a  chronic  osteomyelitis  of 
both  tibia?.  It  begins  as  a  rarefying  osteitis,  passing  on  to  a  con- 
densing osteitis,  metaplasia  of  the  fibrosed  marrow,  and  a  new  peri- 
osteal formation.  Syphilis  and  tuberculosis  can  be  excluded  as 
causative  factors. 

SYMPTOMATOLOGY. 

There  are  tenderness  and  pain  in  the  tibia'  and  fibuhe,  the  bones 
may  become  soft  and  bent  until  the}-  graduall}-  assume  the  boomerang 
curve  with  the  convexitv  outwards. 

The  patient  becomes  flat-footed  and  walks  w  ith  a  shuffling  gait. 

The  subcutaneous  tissues  become  inflamed  and  tender. 

There  is  some  febrile  disturbance. 

The  symptoms  gradually  disappear,  the  bones  resume  their  former 
hardness,  but  the  deformity  remains. 

WHITMORE'S   DISEASE. 
DEFINITION. 

A  septicasmic  infection  of  insidious  onset,  characterized  by  nodules 
and  abscesses  resembling  those  of  glanders  in  the  lungs  and  viscera, 
occurring  in  morphino-maniacs  usually  and  those  addicted  to  the 
cocaine  habit. 

A  bacillus  has  been  found,  but  not  yet  definitely  classified. 

DISTRIBUTION. 

Rangoon. 

^ETIOLOGY. 

It  occurs  in  the  adult  males  of  the  poorer  classes.  It  has  a  close 
relation  to  the  hypodermic  syringe. 

The  isolated  bacillus  has  been  differentiated  from  the  B.  mallei. 
The  diagnosis  is  usually  made  at  the  autopsv. 

SYMPTOMATOLOGY. 

It  is  insidious  in  onset,  usually  occurring  in  broken-down  morphine 
or  cocaine  victims.  There  is  cough  with  pain,  irregular  pyrexia,  furred 
tongue,  slight  ulceration  of  the  tonsils,  broncho-pneumonic  S'gns  and 


4i6 


DISEASES  OF  UNCERTAIN  .ETIOLOGY 


symptoms,  palpable  spleen,  subcutaneous  abscesses,  sometimes  oedema 
of  the  arms  or  legs. 

The  characteristic  lesions  are  "  nockiles  "  of  the  lungs,  liver  and 
kidneys,  the  former  resembling  patches  of  broncho-pneumonia. 

The  abscess  mav  be  subcutaneous  or  intramuscular,  or  in  the  lymph 
glands,  liver  or  spleen. 

The  mesenteric  glands  suppurate,  the  sigmoid  colon  becomes 
ulcerated;  petechias  have  been  seen  in  the  endocardium. 


1 

^HHI 

N| 

1 

^^^^    ^^^^^ 

1 

' 

H 

^ 

H^^   ^^K 

^ 

» 

^ a 

3 

Arm  infected  and  scarred  from    morphine   injections.      Both  arms  were   in  the  same 

condition.     (By  Jefferys.) 

Diarrhoea  has  been  noted. 

The  duration  of  the  disease  is  from  one  to  three  months. 

The  disease  is  also  known  as  Morphine  Injector's  Septicaemia. 


ONYALAI. 
DEFINITION. 

An  acute  infectious  disease  of  unknown  causation,  characterized 
by  the  appearance  of  bulk-e  containing  blood,  on  the  surface  of  the 
body,  the  tongue,  soft  palate,  or  buccal  mucous  membrane. 


AFEBRII.E    SPLENOMF.C.ALY  417 

iETIOLOGY. 

IMense  tliinks  that  it  may  be  some  kind  of  poisoning,  perhaps 
due  to  some  species  of  the  Euphorbiacea?. 

The  disease  was  first  described  by  Yale  Massey  in  Angola,  1904, 
later  on  the  Portuguese  West  Coast,  East  Africa  and  the  Congo. 

SYMPTOMATOLOGY. 

The  onset  is  sudden. 

There  are  lassitude,  a  dazed  appearance,  tender  parotids,  con- 
gestion of  conjunctivas,  slight  fever,  numbness  and  pain  in  various 
parts  of  the  body.  Bullae  appear  on  the  tongue,  in  the  mouth  and 
pharynx,   oesophagus,  stomach  and  bowels. 

The  tongue  is  swollen  and  painful.  There  may  be  vomiting  of 
blood,  and  diarrhoea  has  been  noted. 

Haematuria  and  cerebral  haemorrhage  have  been  described  with  the 
usual  signs.     There  may  be  haemorrhages  in  the  viscera. 

The  bullcT  also  occur  on  the  skin. 

The  disease  may  recur  several  times. 

TREATMENT. 

Arsenic  in  full  doses  should  be  tried. 

Massey  recommends  large  doses  of  sodium  bicarbonate  and  cod- 
liver  oil. 

AFEBRILE    SPLENOMEGALY. 

This  disease  is  also  known  as  Pseudo-Banti's  Disease. 

DEFINITION. 

A  chronic  afebrile  disorder  characterized  by  splenomegalv  and 
severe  anaemia. 

DISTRIBUTION. 

Tropica]  Africa,   Ceylon,   India,  and  probably  elsewhere. 

SYMPTOMATOLOGY. 

The  onset  is  insidious.     It  attacks  children  and  adults  alike. 
There  is  a  painless  enlargement  of  the  spleen  without  enlargement, 
of  the  liver  or  other  organs. 

There  is  a  severe  anaemia,  but  no  parasites  are  found. 
It  has  been  differentiated  from  other  tropical  maladies. 

TREATMENT. 

This  is  symptomatic.     Iron  and  arsenic  are  useful. 


SECTION  V. 
DISEASES  DUE  TO  VENOMS  AND  POISONS 

INTRODUCTORY  REMARKS. 

REPTILES. 

General  Features. 

Classification. 

Distribution  and  Peculiarities. 

The  Venom  Apparatus. 

The  Characters  of  the  Venom. 

The  Varieties  of  Venom. 

The  Symptoms  of  Snake  Bite. 

The  Treatment  of  Snake  Bite. 

Prophylactic  Measures. 

FISHES. 

TOADS  AND   SALAMANDERS. 

ANEMONES,    CORALS   AND   JELLY-FISHES. 

HELMINTHS. 

5C0RPI0NS  AND  SPIDERS,   MITES   AND   TICKS. 

CENTIPEDES. 

LICE  AND  BUGS. 

BEES  AND  WASPS. 

ANTS  AND   CATERPILLARS. 

MOSQUITOES. 

BEETLES,    SNAILS   AND  LIZARDS. 

POISONS    TAKEN   ACCIDENTALLY    BY    MAN. 

ACKEE    POISONING.     THE   VOMITING    SICKNESS   OF   J.A.MAICA. 

POISONS   USED   IN   ORDEALS,   P  IGHTING,  FISHING,   HUNTING. 


REPTILES  419 


DISEASES    DUE    TO    VENOMS    AND     POISONS. 

INTRODUCTORY  REMARKS. 

Venoms  are  useful  :  — 

(i)  To  keep  off  enemies  by  discharging  the  venom  into  the  sur- 
rounding medium,  e.g.,  toads,  salamanders. 

(2)  To  aid  nourishment  by  the  animal  mixing  the  venom  with  its 
own  digestive  juices,  e.g.,  snakes. 

(3)  To  serve  as  a  means  of  attack  or  defence  by  inoculating  the 
venom,  e.g.,  snakes,  scorpions,  &c. 

Animals  are  venomous  only  when  they  are  capable  of  inoculating 
their  venom.     Among  these,  reptiles  form  the  greater  part. 

Humanity  has  held  strange  and  contradictory  ideas  with  regard  to 
reptiles  all  down  the  ages.     For  example  :  — 

In  Genesis  the  serpent  represented  the  Evil  One. 

In  Greece  it  symbolized  wisdom  and  prudence. 

In  Egypt  it  was  the  protector  of  crops  and  represented  immortalit}-. 

In  Rome  its  presence  caused  epidemics  to  cease. 

In  India  the  living  Xaja  represents  happiness  and  prosperity,  the 
dead  reptile,  terrible  calamity. 

There  is  an  average  of  25,000  deaths  per  annum  from  snake-bite  in 
the  Indian  Peninsula  alone. 

300,000  vipers  have  been  killed  in  Haute-Saone,  France,  during 
twenty-seven  years  (Calmette). 

It  is  interesting  to  note  that  the  blood  also  of  vipers,  toads  and 
salamanders  is  toxic  and  that  the  eggs  too  carry  the  venom. 

REPTILES. 
GENERAL  FEATURES. 

A  thick  epidermis  covering  the  skin  is  detached  or  moulted  three 
or  four  times  yearly  in  all  except  a  few  species  of  snakes,  and  these 
retain  a  few  rings  at  the  tip  of  the  tail  as  in  the  rattlesnake,  by  means 
of  which  it  makes  the  noise  so  characteristic  of  it.  This  moult  is  pre- 
ceded by  several  weeks  of  torpor  during  which  the  reptile  does  not  eat. 
The  epidermis  becomes  dull,  dry  and  wrinkled,  later  cracking  at  the 
mouth  after  which  the  reptile  awakes,  shakes  itself  free  from  the 
remainder  and  goes  once  more  in  search  of  food. 

Their  coloration,  governed  generally  by  mimicry,  is  not  of  much 
value  for  diagnostic  purposes  as  it  may  be  modified  several  times 
during  the  life  of  the  same  reptile. 


420 


DISEASES    DUE    TO    VENOMS    AND    POISONS 


The  scales  and  shield  (ihe  latter  are  simply  large  scales  that  do  not 
overlap)  serve  to  differentiate  the  species.  The  ventral  scales,  moved 
by  the  ends  of  the  ribs,  serve  the  purpose  of  locomotion.     The  tongue 


a,  head  u{  JVa/a  bungariis,  showing  occipital  shields;  b,  maxilla  of  Detidraspis ;  c,  Btin- 
garus  candidits,  showing  enlarged  vertebral  scales  ;  d,  laterally  compressed  tail  of  sea-snake  '■> 
e,  head  of  Cattsus  rhombeatus,  showing  large  shields  ;  f,Cerasles,  showing  oblique  lateral  scales  > 
,<,',  head  of  Ancistrodon,  s^howing  large  shields  ;  h,  head  of  Bids,  showing  supra-nasal  shield  and 
small  scales  between  nasal  and  rostral  shields. 


is  long,  very  retractile,  forked  at  the  tip,  is  capable  of  considerable 
protrusion  but  is  harmless.  Some  large  lizards  also  possess  a  similar 
organ. 

The  eyes  have  no  eye-lids;  the  cloaca!   orifice   is  transverse;   the 
mouth  is  most  extensile.     This  latter  feature  is  permitted  largely  owing 


REPTILES 


421 


to  the  lower  jaw   being  attached   to   the   upper   by   means  of  elastic 
ligaments  which  permit  of  considerable  distension. 

The  teeth  are  used  for  holding  and  poisoning  the  victim  in  some 


tn 


i.  Head  of  Lachesis,  showing  loreal  pit  {/.  /.)  ;  k,  head  of  Vipera  bertis, 
showing  shields  and  scales  ;  /,  skull  of  Crotalus,  showing  oblique  maxilla  and 
long  transpalatine  ;  m,  skull  of  Python,  showing  inter  alia  absence  of  mandibulai 
symphysis. 


instances  but  not  for  mastication.  The  victim  is  swallowed  whole,  even 
though  it  be  three  times  the  diameter  of  the  snake,  the  mouth  parts  are 
drawn  over  it  like  a  glove  until  the  whole  has  disappeared.     Deglu- 

27 


422 


DISEASES    DUE    TO    VENOMS    AND    POISONS 


tition  is  slow  and  painful,  but  digestion  is  powerful  and  rapid,  so  that 
the  bones  themselves  are  dissolved. 

There  are   some   lizards   that   possess   snake-like   features,    but   on 


'  f 

a,  Cranial  skeleton  of  one  of  the  non-poisonous  Cohibridx  {Ptyas  mucosus)  ;  3,  cranial 
skeleton  of  one  of  the  poisonous  Cohihrida  {Naja  tripudians)  ;  c,  cranial  skeleton  of 
one  of  the  poisonous  Coluhrida  [Bungarus  fasciaius) ;  d,  cranial  skeleton  of  one  of  the 
Viperidce  (Vipera  russellii) ;  e,  cranial  skeleton  of  one  of  the  Viper  idx  Crotalina  {Crotalus 
durussis)  ;  /,  cranial  skeleton  of  one  of  the  Colubrida  Hydrophiime  [Hydrophis pelamis). 


examination  it  will  be  found  that  they  do  not  have  extensile  jaws, 
but  they  do  have  eyelids  and  an  external  ear,  which  latter  organ  snakes 
do  not  possess. 

For  details  see  a  larger  work. 


REPTILES 


<23 


CLASSIFICATION. 

The  Reptilia  include  two  orders  of  importance  to  the  tropical 
medical  officer,  viz.  :  The  Ophidia  and  the  Lacertilia.  The  former 
is  all  important  as  it  contains  the  venomous  reptiles.  The  Ophidia  con- 
tains two  important  families,  viz.  :   The  Colubrid^e  and  the  Viperid^. 

(I)  The  Colubridae. 

These  form  nine-tenths  of  the  order  Ophidia.  All  snakes  other 
than   pythons  and   vipers  belong  to   it.     There   are   three  groups: — 

(i)  Aglypha.  These  have  solid  ungrooved  teeth.  Their  saliva  is 
toxic  to  rats  and  mice  but  not  to  man.  Among  them  are  the  common 
British    snake    (Tropidonatus    natrix),     the    North    American    water 


Poison-gland    and  fangs  of  a  venomous  snake  {Nafa  tri- 

pudiatts,   Cobibridct).      (Natural  size.) 

L,  Lobe  of  the  gland  ;  D,  poison-duct  ;  F,  fang  attached 

to  the  maxillary  bone  ;  G  G,  gland  ;  M,  capsule  of  mucous 

membrane    surrounding    the    fangs ;     R,    reserve   fangs ; 

A  A,  muscular  fascia  covering  the  gland. 

(After  Sir  Joseph  Fayrer.) 


mocassin  (T.  fasciatus),  the  Indian  rat  snake  (Zamenis  mucosus),  and 
the  African  egg-eating  snake  (Dasypeltis  scabra). 

(2)  Opisthoglypha.  {oTTLaOev  =  behind;  ')\v<p7]  =  a  groove). 
These  have  one  or  more  of  the  hinder  teeth  in  the  upper  jaw  grooved. 
As  their  fangs  are  situated  at  the  back  part  of  the  mouth  they  are  not 
well  developed  and  are  not  very  harmful  to  man.  Among  them  are 
the  Indian  tree  snakes  (Dipsadomorphin^e),  the  Indian  egg-eating 
snakes  and  water  snakes  (Homalapsiuce). 

(3)  Proteroglypha  (  irporepu  ==  before). — These  have  the  front 
upper  teeth  well  developed  and  grooved  anteriorly,  connected  with 
ducts  leading  from  well-developed  poison  glands.  All  are  dangerous 
to  man  and  animals.     There  are  three  sub-families  :  — 

(a)  ElapincB.  These  live  on  land  and  have  a  cylindrical  tail.  They 
happen  to  be  the  only  poisonous  snakes  known  to  Australia.  Among 
them  are  :  — 

The   Cobra-di-capello,    or   the   snake   with    the   hood,    which   when 


424  DISEASES    DUE    TO    VENOMS    AND    POISONS 


Mongoose  seized  by  a  cobra. 

(For  this  illustration  I  am  indebted  to  the  kindness  of  M.  Claine,  late  P'lench  Consul 

at  Rangoon.) 


Hydrophis  coronatus,     (After  Sir  Joseph  Fayrer.) 


REPTILES 


425 


excited,  expands  the  skin  behind  the  head  by  throwing  outwards  the 
cervical  ribs. 

The  Naja  tripudians,  with  the  spot  or  spectacles  on  its  hood. 

The  N.  haje  or  Cleopatra's  asp. 

The  N.  bungarus  or  large  king  cobra. 

The  Bunbarus,  some  having  yellow  and  black  bands. 

The  Acanthophis  artarcticus,  the  death  adder  with  spines  on  its  tail. 


Na/'a  tripudians  (cobra-di-capello)  on  the  defensive, 
preparing  to  strike. 

The  Elaps  corallinus,  the  coral  snake  with  black,  red  and  yellow 
bands. 

The  Sepedons  or  hooded  snakes,  which  are  supposed  to  "  spit  " 
or  throw  their  venom  some  distance  and  so  cause  severe  conjunctivitis. 
They  are  found  in  Africa,  not  in  Europe  or  America. 

{h)  HydrophincB.  These  all  live  in  the  sea  with  the  exception  of 
a  few  that  have  been  accidentally  cut  off  in  small  lakes.  They  have 
the  tail  flattened  for  swimming,  and  also  in  order  to  attach  themselves 
to  corals  while  feeding.  They  travel  in  companies,  usually  on  the 
surface  of  the  water,  but  they  can  take  in  large  air  reserves  and  dive 
to  great  depths.     They  are  very  dangerous  to  fishermen,  especially  in 


426  DISEASES    DUE    TO    VENOMS    AND    POISONS 

the  Indian  Ocean.     Their  fangs  are  small,  but  the  venom,  though  but 
little  is  injected,  is  the  most  potent  known.     It  is  chiefly  neurotoxic. 

The    Genera    are  :     Distera,     Acalyptus,     Hydrophis,     Enhydrina, 
Hydrelaps,  Hydrus,  Thalassaphis,  Enhydris,  Platurus  and  Aipysurus. 

(II)  Yiperidae. 

These  have  a  triangular  head,  short  neck,  stout  body,  stumpy  tail, 
and  tubular  poison  glands  situated  anteriorly,  which  are  provided  with 


Bung-ants  fasdatus  (India).     (After  Sir  Joseph  Fayrer.) 

fangs  having  a  large  foramen  for  the  venom.  There  are  120  species, 
some  of  which  live  in  trees,  but  all  are  dangerous  to  man.  There  are 
two  groups  :  — 

(i)  Crotalin^,   with  a  deep  sensory  pit  between  the  eye  and  the 
nostril  on  each  side.     These  include  rattlesnakes,  such  as  :  — 

Crotalus,  with  many  small  scales  on  the  top  of  the  head. 

Sisturus,  with  nine  large  scales  on  the  top  of  the  head. 

Ancistrodon. 
(2)  ViPERiN^,   having  no  sensory  pit  as  the  Crotalinas.     Amongst 
them  are  : — 

Vipera  berus,  the  English  adder. 

Vipera  russelli,  the  handsome  Indian  viper. 


REPTILES 

Bitis  arietans,  the  puff-adder  of  the  Gold  Coast. 
Cerastes  cornutus,  the  horned  viper  of  North  Africa. 
Echis  carinatus,  the  viper  of  the  Pyramids. 


427 


Elaps fulvius  (the  harlequin  snake,  or  coral  snake).     (After  L.  Stejncger.) 


DISTRIBUTION  AND  PECULIARITIES. 

In  Asia  are  the  Elapinae,  Hydrophinae,  Viperinai,  and  Crotalinae. 
In  Africa  are  the  Elapin^  and  Viperin;^. 

In  Australia  and  Oceania  are  the  Elapin^  and  Hydrophinae. 
In  America  are  the  Elapinag  and  Crotalinae. 


428  DISEASES    DUE    TO    VENOMS    AND    POISONS 

In  Asia — Here  all  kinds  are  represented. 
(i)  Elapime. 

The  naja  has  a  venom  chiefly  neurotoxic. 

The  bungarus  has  a  single  row  of  scales  on  the  back.     The 
N.  candidus  seldom  exceeds  4  feet  in   length,   is  blue-black  in 


Crotalus  tertificus  (dog-faced  rattlesnake,  cascavella  in  Brazil). 
(After  Stejneger.) 

colour  with  white  or  yellow  bands.  Its  fang  leaves  practically 
no  mark  behind.  Its  venom  is  neurotoxic.  The  natives  affirm 
that  it  breathes  upon  them  while  they  are  asleep  and  thus  kills 
them. 

The  N.  fasciatus  has  alternate  broad  rings  of  bluish-black  and 


REPTILES 


429 


canary-yellow.  On  section  it  is  almost  triangular  in  shape.  It 
has  a  stumpy  tail,  and  for  this  reason  it  has  been  misnamed  the 
two-headed  snake.     It  may  drop  on  to  one's  head  from  above 


Croialus  confliientus  (Pacific  or  mottled  rattlesnake). 
(After  Baird  and  Stejneger.) 

at  any  time.  The  N.  bungarus,  or  king  cobra,  has  killed 
taking  an  average  over  eight  years,  19,880  persons  and  2,100 
cattle  per  annum.  In  1889  it  killed  22,480  persons  and  3,793 
cattle. 


430  DISEASES    DUE    TO    VENOMS    AND    POISONS 

The    hemibungarus,    calloptus    and    adenophis    will    seldom 
attack  one. 

They  must  be  looked  for  in  the  jungle.     They  are  a  cherry, 
red  colour.     Little  is  known  about  their  venom. 


Sistrurus  caienatus  (prairie  rattlesnake,  or  Massasanga). 
(After  Holbrook  and  Stejneger.) 

(2)  Hydrophince. — These   have  already  been   described. 

(3)  Viperince. 

The  nasal  and  rostral  shield  are  in  contact  or  separated  by 
one  shield. 


REPTILES 


431 


Russell's  viper  is  common,  a  reddish-brown  snake  with  a 
series  of  three  black  lozenged-shaped  marks  along  its  body. 

The  bitis  is  also  common.     It  is  described  under  "Africa." 

The  echis  is  seen  in  dry  desert  tracts,  commonly  in  India. 

The  scales  on  the  flanks  are  much  smaller  than  those  on  the 
back,  and  are  at  an  oblique  angle,  toothed  and  ribbed  not  unlike 


Vipera  russellii  {fiyn.,  Vipera  elegatts',  daboia,  or  Russell's  viper),     India. 
(After  Sir  Joseph  Fayrer.) 

a  spear  point.     They  are  aggressive,  and  their  venom  is  highly 
haemolytic  in  action. 
(4)  CrotalincB. 

These  are  found  in  America  and  are  mentioned  later. 


In  Africa. 

The  Elapin^e  and  Viperinae  are  plentiful.     Hydrophynas  are  found 
at  times,  but  are  accidental, 
(i)  Elapince. 

The  Naja  and  its  species  are  known  by  their  hoods  and  their 
erectile    ribs.     The    scales    are    smooth.     The    N.    haje    is    the 


432  DISEASES    DUE    TO    VENOMS    AND    POISONS 

common  cobra  of  North  Africa;  the  N.  llava  of  South  Africa; 
the  N.  milanolanta  and  N.  nigrocolHs  of  Central  Africa. 

The  Sepedon  is  found  only  in  Africa.  The  scales  have  a  keel 
or  midrib.     It  grows  to  a  large  size. 

The  Dentraspis  is  common.  It  lives  in  trees,  and  is  7  to  8  feet 
long,  but  is  not  as  thick  as  the  cobra. 


Bitts  arietafts  (the  puff-adder).     (After  Dumeril  and  Bibron.) 

The  Elapechis  is  distributed  over  Africa  south  of  the  Sahara. 

It  has  a  very  short  tail.     Little  is  known  of  its  venom. 
(2)   Viperince. 

The  Vipera  is  widely  distributed. 
.   The  Bitis  or  puff-adder  is  common.     It  has  a  short  thick  body 
and  carries  enormous  poison  fangs,  often  more  than   i  inch  in 
length.      Between    the    rostellum    and    nasal    shield    there    are 
numerous     small     scales.      The     "pocket"     above     the     nasal 


REPTILES 


433 


aperture  is  protected  by  a  semicircular  shield.  The  venom  is 
h^emolytic,  and  a  good  bite  is  usually  fatal. 

The  Bitis  arietans  is  pretty,  with  V  markings  down  the  back. 

The  nostrils  are  vertical  and  not  lateral. 

The  Echis  abounds  here  as  elsewhere. 

The  Serastis  is  all  over  the  Mediterranean  region.  They 
differ  from  the  Echis  by  having  a  ridge  along  each  side  of  the 
abdominal  shields. 

The  Atheris  differs  from  the  above  by  the  scales  on  the  flanks 


Echis  carinaitis.     India.      (After  Sir  Joseph  Fayrer.) 

being  smaller  and  not  serrated.     They  are  of  a  greenish  tint  and 
live  in  trees. 

The  Causus  is  found  in  all  parts  of  tropical  Africa.  The 
crown  of  the  head  is  covered  with  large  shields.  There  is  often 
a  neat  broad  arrow-head  marking  on  the  dorsum  of  its  head. 
It  is  usually  brownish  in  colour.  The  venom  is  strongly 
haemolytic. 


In  Australia. 

{i)  Hydrophince  are  plentiful. 

{2)  ElapincB  are  numerous,  and  here  are  to  be  found  twice  the 
number  of  species  possessed  by  any  other  country.  Australia 
may  be  looked  upon  as  the  headquarters  of  this  family.  Some 
are  not  unlike  vipers. 


434  DISEASES    DUE    TO    VENOMS    AND    POISONS 

In  America. 

HydrophincB  are  accidental, 
(i)  ElapincB, 

There  is  only  one  genus  but  many  species.     The  venom   of 


Lackesis  neuwiedii  (known  as  the  ttrutu  in  Brazil). 
(After  Lacerda.) 


the  Elapis  is  very  deadly.  They  are  beautifully  coloured, 
broad  rings  of  black  and  red  alternately;  there  may  also  be 
narrower  yellow  rings  between  these. 


THE    VENOM   APPARATUS  435 

(2)  Crotalince. 

These  are  very  abundant.  A  large  sensory  pit  leading  down 
to  the  maxilla  will  help  in  the  diagnosis. 

The  Lachesis  is  a  jungle  snake,  and  has  its  head  covered  by 
small  scales,   never  shields.     It  is  also  seen  in  Asia. 

The  L.  mutis  is  very  deadly.  It  attains  to  14  feet  in  length 
and  is  very  aggressive.  It  has  enormous  fangs.  The  tail  is 
short  and  covered  by  pointed  scales,  and  not  shields. 

The  Fer  de  Lance  is  also  very  deadly. 

The  Ancistrodon  is  a  fatal  reptile,  but  its  venom  has  not  been 
much  studied.  The  crown  of  the  'head  is  covered  by  large 
shields  which  are  in  contact  with  each  other.  It  is  also  present 
in  India  and  Southern  Asia. 

The  Crotalus  or  rattlesnake  only  exists  in  America.     Its  bite 

is  exceedingly  dangerous.     Pigs  are  their  sworn  enemies  and 

.    eagerly  devour  them.     Their  resistance  may  be  due  to  the  thick 

layer    of    subcutaneous    adipose    tissue,    which    is    but    slightly 

vascular  and  slowly  absorptive. 

THE  VENOM  APPARATUS. 

There  are  some  non-poisonous  snakes  that  possess  poison  glands, 
but  the  means  of  inoculating  the  venom  are  absent.  It  is  used  in 
digesting  its  prey. 

The  venom  gland  of  poisonous  reptiles  resembles  the  modified 
parotid  of  adult  persons.  The  venom  gland  is  situated  at  the  sides  of 
the  head  and  behind  the  eyes.  It  is  covered  by  the  masseter  muscle, 
which  when  contracted  presses  upon  the  gland  and  forces  out  its 
poisonous  contents.  In  some  snakes  the  gland  is  like  a  long  ribbon 
passing  along  one-third  of  the  body  underneath  the  skin.  The  gland 
is  always  covered  by  a  tough  fibrous  capsule  attached  to  the  articula- 
tion of  the  lower  jaw.  When  the  animal  bites,  this  capsule  is  pressed 
upon  and  the  venom  is  forced  along  the  duct.  The  duct  is  situated 
just  above  the  line  of  the  lip  to  a  point  below  the  eye,  and  ends  in  a 
small  papilla  or  "pocket"  of  loose  mucous  membrane  into  which  the 
base  of  the  fang  is  inserted.  There  is  one  fang  at  each  side  in  action 
at  the  same  time,  but  reserve  ones  are  always  ready,  and  should  one 
be  broken  it  can  readily  be  substituted.  The  venom  runs  along  a 
groove  on  the  anterior  surface  of  the  tooth  or  fang,  or  down  a  canal 
formed  by  the  sides  of  the  groove  coalescing.  The  duct  does  not  come 
directly  to  this  groove,  but  terminates  in  the  papilla  or  small  sac 
described.  Vipers  have  the  longest  fangs,  nearly  i  inch  in  length. 
The  fang  projects  downwards  and  backwards  in  the  closed  mouth  and 
is  firmly  attached  to  the  alveolar  process.  Owing  to  the  free  mobility 
of  the  cranial  bones  the  tooth  can  be  made  "  erectile  "  for  piercing. 


436  DISEASES    DUE    TO    VENOMS    AND    POISONS 

In  striking  liie  body  is  coiled,  the  tail  projecting,  the  head  and 
neck  raised  a  few  inches,  the  tongue  darts  to  and  fro,  air  passes  forcibly 
through  the  narrow  glottis,  causing  hissing,  the  muscles  contract,  the 
snake  straightens,  the  head  suddenly  darts  forwards  and  upwards  as 
required,  the  thrust  being  one-third  to  one-half  of  its  body  length. 
The  jaws  are  widely  separated,  the  head  bent  back,  the  superior 
maxillary  bone  is  rotated  forwards  upon  its  lachrymal  articulation,  and 
thus  erects  the  fangs.  The  jaws  are  approximated,  the  fangs  enter 
the  victim,  the  head  is  drawn  violently  backwards,  and  the  teeth  are 
driven  deeply  into  the  flesh.  Tlie  lower  jaw  presses  upwards  and  so 
squeezes  fluid  from  the  gland  along  the  duct,  and  injects  the  venom 
forcibly  into  the  wound  at  the  same  time  as  it  is  being  enlarged.  In 
disentangling  itself  the  fang  may  be  lost,  but  this  is  of  little  moment 
as  others  soon  arrive.  Unless  the  fangs  become  erectile  no  Avound  is 
made  and  the  venom  will  flow  upon  the  skin,  doing  no  harm. 

U  is  very  doubtful  if  any  snakes  "  spit  "  venom.  The  amount  that 
can  be  injected  varies  with  the  species  of  reptile;  its  previous  condition 
of  full  or  impaired  nutrition;  its  nearness  to  the  moulting  period;  and 
according  to  the  pressure  applied  to  the  gland. 

Also  by  captivity,  interference  of  clothing,  failure  of  the  snake  to 
close  its  jaws,  deficient  elevation  of  the  fangs,  malapposition  of  the 
orifices  of  the  poison  duct  and  the  fang,  and  the  rapid  movement  of 
the  victim  attacked,  thus  shaking  off  the  snake  before  it  had  time  to 
shut  its  jaws. 

Sea  snakes  inject  but  a  few  drops  of  venom  which  are  very  deadly. 
The  Indian  cobra  can  inject  i  drachm.  Snakes  in  captivity  always 
yield  less  venom.  The  Naja  haje  can  produce  about  0*36  grm.  of 
liquid  in  100  days,  i  grm.  of  which  yields  about  0*336  grm.  of 
dry  venom. 

Acton  and  Knowles  have  done  some  excellent  work  on  this  subject 
in  India.  In  their  results  their  unit  is  as  far  as  possible  expressed  in 
milligrammes  of  desiccated  venom.  The  yield  of  venom  was  ascer- 
tained to  be  for  the — 


Common  cobra 

(50 

observations) 

mean 

yield 

•••     317  mgm 

Common  krait 

(48 

)5 

)' 

,,          ... 

8       „ 

Banded  krait 

(27 

)) 

M 

,,          ... 

...       64      „ 

Russell's  viper 

(6 

)1 

M 

??          ... 

...     108       „ 

Echis  carinatus 

(57 

'J 

)) 

,,          ... 

...       18       „ 

Lachesis  gramineus 

(15 

» 

)' 

,,          ... 

•••       30      „ 

The  minimum  lethal  dose  for  man  was  estimated  ingeniously. 
They  took  the  common  cobra  bite  and  studied  all  cases  from  classical 
writers  of  fatal  bites,  from  the  study  of  which  they  concluded  that 
I3"6  mgm.  would  just  fail  to  kill  a  man,  hence  15  mgm.  would  just  be 
fatal. 


THE    J-RNOM   AriWRATUS 


437 


Having-  in  this  way  formed  a  standard  minimum  lethal  dose  of 
cobra  venom  for  man,  viz.,  15  mgm.,  they  carried  out  experiments  on 
monkeys,    using  the   first    figure   as   a   control,    giving   the   desiccated 


Feeding  a  poisonous  snake,  first  stage. 


Feeding  a  poisonous  snake,  second  stage. 
» 

venom   subcutaneously.     On   this  basis  tiie  minimum   lethal   dose  for 
other  reptiles  was  :  — 

Common  cobra,  15     |       Bungarus  Candidas,  i 
Naja  tripudians,  15  ,.  fasciatus,  10 

„     bungarus,  12  \'iper  russelli,  42 


Echis  carinatus,  5 
Lachesisgramineus,  probably 
more    than    any  one  snake 

could  slied  at  anv  one  time. 


They  then  estimated  how  much   venom  several   species  of  snakes 
could  inject  at  one  bite.     This  they  estimated  by  obtaining  the  venom 
28 


3 

42 

72 

12 

14 

438  DISEASES    DUE    TO    J'ENOSiS    AXD    POISONS 

from  the  snakes  in  question,  and  estimating  two-thirds  of  the  quantity 

obtained  as  the  amount  which  could  be  injected  at  once.     The  resuhs 

were  :  — 

Naja  tripudians  ...         ...         ...     21 1  mgm.  of  desiccated  venom 

Bungarus  candidiis  ... 

„  fasciatus  ... 

Vipera  riisselli 
Ecliis  carinatLis 

Lachesis  gramineus  ... 

This  was  when  the  snakes  were  heahhy,  in  full  natural  vigour,  not 

exhausted,  roused  from  hibernation  or  in  captivity. 

THE  CHARACTERS  OF  SNAKE  YENOM. 

Collect  the  venom  bv  chloroforming  the  snake  and  squeezing  the 
venom  into  a  vessel.  Dry  it  c{uickly  in  a  desiccator  over  sulphuric 
acid.  When  dry  it  will  remain  potent  for  years.  In  the  fluid  form  it 
is  transparent,  slightly  3'ellowish,  odourless,  acid  in  reaction,  bitter  to 
the  taste,  syrupy,  of  a  specific  gravity  1030- 1060,  readily  soluble  in 
water  or  saline,  rich  in  soluble  albumins  which  are  its  toxins.  All  its 
toxic  substances  are  precipitated  by  absolute  alcohol.  The  venom  is 
destroyed  by  strong  acids,  alkalies,  potassium  permanganate,  boiling 
or  by  anything  that  "  kills  "  ordinary  albumin.  Gastric  juice  destroys 
that  of  the  Colubrinas  and  pancreatic  juice  that  of  the  Viperin^e.  When 
dry  it  is  not  unlike  iodoform  in  appearance.  It  can  decompose  and 
change  its  colour.  Light  causes  it  to  deteriorate  when  in  the  fluid 
state,  but  it  does  not  affect  it  when  dry  to  any  great  extent.  Fluid 
venom  may  readily  be  contaminated  b}'  micro-organisms  of  all  kinds. 
Glycerine  in  ecjual  parts  is  a  good  preservative.  Its  toxicity  is  increased 
during  starvation,  and  in  dry  climates  in  the  same  snake  species.  The 
effects  vary  A\ith  the  amount  injected,  the  species  of  snake,  the  site  of 
the  injection,  viz.,  skin,  muscle,  or  blood-stream,  and  other  factors. 

THE   VARIETIES  OF  YENOM. 

Snake  venoms  are  very  complex  liquids,  each  containing  some  of 
the  following  active  principles  :  — 
(i)  Neurotoxins. 

Some  act  on  ihe  vasomotor  centre. 

Others  act  on  the  respiratorv  centre. 

Others  on  the  nerve  endings  in  muscle,  especiallv  of  the  phrenics. 

(2)  Agglutinins. 

(3)  Cytolysins. 

Some  are  iKcmolvsins. 
Others  are  leucolysins. 
Others  are  hccmorrhagins. 
Others  are  simple  cytolysins. 


THE    VARIETIES    OF    VENOM 


439 


Catching  a  cobra-di-capello  {Naja  tripudians),  first  stage. 
(At  the  French  settlement  of  Pondicherry,  in  India.) 


:v\\-x   V' 


^i'i^?-^ 


Catching  a  cobra-di-capello  {Naja  iripiuiians),  second  stage. 
(At  the  French  settlement  of  Pondicherry,  in  India.) 


440  DISEASES    DUE    TO    J'ENOMS    AND    POISONS 

(4)  .Vnlihccmolysins. 

(5)  Antibacterial  substances. 

(6)  A  fibrin  ferment. 

(7)  An  a  mi  fibrin  ferment. 

(8)  A  proteolytic  ferment. 

(9)  A  cardiac  tonic. 

Xiniibers  (i),  (3)  and  (())  are  the  most  important. 
Xo  one  snake  yields  all  these  varieties  of  venom. 

To  analyse  Snake  Yenom  (Martin). 

(i)  Dialysing  and  filtering  it  through  a  gelatine  filter,  supported 
in  the  pores  of  a  Pasteur-Chamberland  filter.  Fibrin  ferments  and 
hsemorrhagins  do  not  dialyse. 

(2)  Heat  from  70°  to  100°  C.  Some  neurotoxins  and  hc'emolysins 
will  not  be  affected. 

(3)  Digest  ^\ilh  red  blood  cells  and  serum,  previously  heated  to 
50°  C.  The  hcemol}sins  are  thus  separated  from  the  neurotoxins. 
The  erythrocytes  remove  the  h^emohsins ;  the  heating  removes  the 
hasmorrhagin,  so  that  the  neurotoxin  alone  remains. 

Neurotoxins  are  very  important.  The  venom  of  the  Colubrinae 
contains  much.  It  unites  with  the  nerve  cells,  attacks  the  respiratory 
centre  in  the  medulla,,  reducing  the.  respirations  in  number  and 
amplitude  to  cessation,  and  paralyses  the  jDhrenic  end  plates  in  the 
diaphragm.  The  circulation  ma\'  be  kept  going  for  some  time  after 
ces.sation  of  breathing  if  artificial  respiration  be  resorted  to. 

The  venom  of  some  snakes,  however,  sucii  as  A'iper  russelli,  Bitis 
arietans.  Crotalus  horridus,  and  Lachechis  anamallensis,  contains  a 
neurotoxin  that  acts  upon  the  vasomotor  centre  of  the  medulla  affecting 
the  blood-pressure.  When  the  nerve  cells  are  attacked  the  Nissl 
granules  break  up  into  a  fine  dust-like  deposit,  the  nucleus  remains 
central  but  indistinct.  In  sudden  death  no  change  is  noted.  The  cells 
are,  as  a  rule,  unequally  effected. 

Agglutinins. — These  are  destroyed  by  heating  to  75°-8o°  C.  White 
and  red  cells  may  be  agglutinated.  To  see  this  reaction,  add  a  10  per 
cent,  solution  of  dried  venom  in  normal  saline  to  washed  corpuscles 
suspended  in  normal  saline.     The  cellular  outline  mav  be  modified. 

Cytolysins  are  of  four  groups  :  — 

Hasmolysins. — A  2  per  cent,  solution  of  the  \'iper  berus  venom 
and  a  o*i  per  cent,  solution  of  Pseudechis  venom  destrovs  red  cells  in 
eighteen  to  twenty-four  hours.  These  also  remove  the  antibactericidal 
properties  of  the  blood  in  most  instances,  but  not  in  the  case  of  the 
Necturus.  The  .same  venom  that  acts  upon  human  red  cells  mav  not 
act  upon  those  of  other  animals;  this  feature  depends  solelv  upon  the 


THE    SYMPTOMS    Of    SNAKE    HITE  441 

amouni  of  fatly  acids  conlained  in  the  corpuscles.  If  plentiful  the  red 
cells  are  readily  affected,  but  if  scarce  they  are  not  so  readily  destroyed. 

Leucolysins. — \Veir  .Mitchell  and  Reichert  notice  that  the  mobility 
of  the  leucocytes  absolutely  cea.sed  in  Crotalus  poisoning.  The  white 
cells  become  stationary,  granular  and  swollen,  their  outlines  becoming 
indistinct  and  then  disappear.  The  lymphocytes  are  affected  last. 
Cobra  poisoning  is  very  vigorous  in  this  respect. 

Haemorrhagin  has  the  power  of  so  damaging  the  vessel  walls  as  to 
form  actual  rents  therein,  permitting  the  blood  to  escape  from  them. 
The  destruction  is  due  to  a  cytolytic  action  upon  the  endothelial  cells 
of  the  vessels  and  not  to  a  bursting  of  the  capillary  wall. 

Other  cvtoh-sins  act  upon  the  cells  of  the  liver,  kidney,  testicle 
and  ovarv,  causing  lysis  of  same.  The  cells  of  the  kidney  tubules  arc 
necrotic  and  detached,  filling  the  lumen.  There  are  congestion  and 
interstitial  haemorrhages. 

Antihcpmolysins  are  contained  in  some  viper  venoms  which,  if 
added  to  red  cells  in  a  certain  concentration,  will  not  allow  haemolysis 
to  take  place.  Perhaps  it  is  due  to  precipitating  the  outer  layer  of 
hccmoglobin. 

Antibactcricidal  substances  have  been  suspected  because  animals 
killed  bv  snake  venom  rapidlv  decompose.  It  has  been  shown  that  the 
serum  complements  are  fixed,  and  hence  the  bactericidal  properties  of 
normal  sera  are  destroyed. 

Fibrin  jermcnt  exists  in  the  venom  of  the  ^"iperin^e  and  Colubridas. 
Vascular  clotting  is  caused,  convulsions  and  sudden  death  resulting. 

Antifihrin   ferment  is  found  in  cobra  and  allied  venoms. 

Prolcolytic  ler}iu'nts  \\ere  suspected  because  the  muscle  fibres  at  the 
site  of  the  bite  Avere  rapidl}'  softened  by  crotalus  Aenom.  Gelatine 
is  lic|uefied  by  it.  The  muscle  fibres  become  necrotic  and  degenerate 
with  a  local  pol\morphonuclear  infiltration. 

A  Cardiac  and  ]'asciihir  tonic  is  indicated  bv  the  stimulation  of 
the  heart  and  the  continuous  circulation  after  the  cessation  of  respira- 
tion, if  artificial  respiration  is  continued  in  cases  resulting  from  the 
inoculation  of  cobra  venom. 

Exactly  how  it  has  been  produced  has  not  been  demonstrated. 

THE  SYMPTOMS  OF  SNAKE  BITE. 

Colubrine  Yenom,  e.g.,  Xaja  tripudians  (aphidismus  =  snake 
poisoning). 

On  Animals. — Paralysis  of  tongue,  larynx,  pharynx  and  all  volun- 
tary movement,  salivation,  cessation  of  respiration,  lachrvmation, 
mucous  discharge  from  nose,  respiratory  passages  and  stomach,  local 
inflammation,  pain,  engorgement,  effusion,  suppuration  and  sloughing. 


442  DISEASES    DUE    TO    J^ENOMS    AND    POISONS 

There  is  haemolysis,  reduced  coagulabilily  and  hc-ematuria.  If 
much  venom  is  injected  there  is  not  sufficient  time  for  some  of  these 
t(j  appear,  such  as  suppuration,  &c. 

On  Man. —  Local  pain,  two  small  puncture  wounds  three-quarters 
of  an  inch  apart  exuding  blood-stained  fluid.  Pain  increases,  spreads 
up  the  limb;  patient  feels  intoxicated,  loses  control  of  legs  with 
paralysis  of  jaw  and  other  muscles;  often  profuse  salivation  and 
inability  to  speak  or  swallow.  Pulse  and  respiration  increase,  respira- 
tion then  decreases  and  stops.  The  heart  continues  to  beat  for  a  short 
time  longer.     If  recovery,  much  urine  is  passed. 

P.M. — Rigor  mortis  marked,  blood  fluid  (coagulated  in  animals), 
parotids  swollen,  pia  mater  engorged,  muscles  a  dirty  red,  lungs 
congested,  bronchi  contain  a  thin  frothy  fluid,  right  heart  distended 
with  blood,  liver  congested  and  dark,  bladder  contracted,  fatty 
degeneration  of  liver  and  kidney,  necrosis  of  renal  and  hepatic  epithe- 
lium, round-celled  infiltration  of  bile  ducts. 

The  symptoms  and  post-mortem  findings  vary  slightly  with  the 
species  of  Colubrine  and  the  amount  of  venom  injected. 

Elapine  Yenom — In  Australia,  where  Elapines  are  common,  the 
symptoms  are  :  local  swelling,  and  pain  with  constitutional  symptoms 
in  from  one-half  to  two  hours.  Weakness  of  legs,  prostration,  vomit- 
ing, heart  weakens,  extremities  become  cold  and  skin  blanched. 
Respiration  is  slowed,  coma  intervenes,  sensations  are  diminished, 
pupils  dilate,  convulsions  sometimes,  and  death.  The  heart  continues 
after  respiration  has  ceased. 

The  Elaps  fulvius,  the  harlequin  snake  of  the  Southern  States  of 
America,  causes  great  local  pain  and  drowsiness  in  one  hour,  uncon- 
sciousness, collapse  and  death  in  twenty-four  hours.  If  recovery, 
danger  is  not  passed  until  the  fifth  day,  as  the  symptoms  tend  to  recur. 

Hydrophine  Yenom — Almost  purely  neurotic.  This  differs  from 
the  Colubrine  effects  as  follows  :  It  is  more  toxic,  less  h^emolytic,  and 
hence  causes  less  stained  local  effusion,  and  does  not  affect  the 
coagulability  of  the  blood.  Symptoms  are  delayed,  then  there  is 
stiffness,  suffocation,  spasms,  vomiting,  convulsions,  and  death  after 
a  day  or  two.     Local  reaction  slight. 

Yiperine  Yenom — That  of  Russell's  viper  is  the  most  fatal;  a  dog 
bitten  may  drop  dead  in  from  twentv  to  forty  seconds.  The  cause  of 
death  is  intravascular,  the  clotting  is  most  marked  in  the  portal  vein. 
More  chronic  cases  show  much  local  oedema,  extensive  subcutaneous 
haemorrhages,  sloughing  of  this  area  (or  resolution),  or  abscess  forma- 
tion or  spreading  gangrene.  There  is  rapid  emaciation,  profound 
anaemia,  hematuria  and  mel^ena.  In  these  cases  the  blood  is  cherry- 
red  and  Avill  not  clot;  there  is  bleeding  everywhere.  The  leucocytes 
are  useless.     Secondarv  septicaemia  is  to  be  expected. 


THE    TREATMENT    OP   SNAKE   BTTE  443 

In  iMan.—  LocLil  pain,  swelling,  lividity.  Rapid  swelling  and 
spreading  decoloration,  excitement,  thready  pulse,  hurried  respirations, 
and  later,  stertorous  breathing.  Cold  universal  sweat,  the  swelling 
reaches  the  trunk,  convulsions,  and  dealli  from  failure  of  the  circulation 
ensue. 

P.M. — Meninges  and  lungs  congested. 

The  Bitis  arietans  or  puff  adder  is  the  same  in  kind  but  less  severe. 

The  Echis  is  very  poisonous;  its  effects  are  much  as  the  Colubrine. 

Crotaline  Venom,   e.g.,   Crotalus  horridus. 

Local  oedema,  swelling,  infiltration  of  incoagulable  blood,  necrosis, 
suppuration,  sloughing.  Fall  in  B.P.  accompanied  by  vaso-dilatation 
of  the  portal  svstem,  respiration  gradually  ceases  due  to  the  failure  of 
the  circulation.  The  phrenics  are  not  paralysed,  and  the  respiratory 
centre  is  not  primarily  affected.  There  are  hcCMiiorrhages  into  the  peri- 
and  endo-cardium,  peritoneum,  and  pleurc'c  but  not  into  the  nervous 
system.     There  is  no  primary  stimulation. 

Few  persons  die  of  snake  bite  compared  with  the  number  alleged  to 
have  been  bitten  by  venomous  reptiles.  30  per  cent,  has  been 
suggested. 

THE  TREATMENT  OF  SNAKE  BITE. 

The  indications  are  :  — 

(i)  To  prevent  the  absorption  of  venom. 

(2)  To  neutralize  the  venom  absorbed. 

(3)  To  aid  the  excretion   of  the  venom. 

(4)  To  maintain  the  strength  of  the  patient. 

(5)  To  treat  the  symptoms  as  they  arise. 

(6)  To  prevent  as  far  as  possible  secondary  infection. 

(1)  To  Prevent  the  Absorption  of  Venom. 

Stop  the  flow  of  blood  and  lymph  from  the  bitten  area  by  ligature. 
This  must  be  slackened  for  two  seconds  at  intervals  and  must  be 
applied  for  half  to  one  hour.     This  allows  time  :  — 

For  the  dilution  of  the  venom  absorbed  already. 
For  the   neutralizing  process  to   commence. 

And  permits  of  a  gradual  absorption  only  from  the  affected  area. 

Open  the  poisoned  area  freely  for  the  application  of  antidotes  and 

the  local  excretion  of  venom;  this  to  be  along  the  vessels  in  particular. 

The   bite   of   the    Echis,    however,    usually    bleeds   so    freely   that    the 

difficulty  is  in   controlling  it. 

Pour  into  the  wound  a  strong  solution  of  potassium  permanganate 
and  wash  it  well  into  the  wound,  attempting  thus  to  neutralize  some  of 
the  venom  locally.  Use  crystals  if  there  is  no  water  available.  Some 
find  I  per  cent,  chromic  acid  or  hypochlorite  of  lime  useful. 


444  DISEASES    DUE    TO    J'EA'OMS    AXD    POISONS 

Applv  boric  acid  fomentations,  frequently  repeated,  followed  b}-  a 
mild  antiseptic  dressing  when  the  wound  heals. 

Suck  the  wound.  Gastric  and  pancreatic  juice  neutralizes  most 
venoms. 

Care  should  be  exercised  that  there  are  no  abrasions  about  the 
mouth  or  lips.  W^iih  some  venoms  the  operation  is  not  always  free 
from  risk. 

(2)   To  neutralize  the  Venom  absorbed. 

Tliis  includes  the  attempt   to  procure  an  acquired  immunity,   so  a 
few  remarks  upon  the  subject  of  immunit)-  as  applied  to  snake  venoms 
will  not  be  superfluous. 
Natural  Imrmmity. 

The  mongoose  and  some  hedgehogs  are  believed  to  be 
immune  to  cobra  bite.  Pigs  are  less  acutely  affected  owing  to 
a  thick  but  slighty  vascular  layer  about  the  body.  In  South 
America  there  is  a  harmless  Colubrine,  the  mussurana,  that 
fights,  conquers,  and  eats  the  largest  venomous  reptiles  in  that 
continent  wdthout  any  obvious  s\'mptoms.  Perhaps  this  reptile 
could  be  used  therapeuticalh-. 
A cq uired  I m  m un ity . 

The  natives  of  Bushmanland,  Xamaqualand  and  Damara- 
land  are  said  to  drink  snake  venom  for  the  sake  of  its  protection. 

Some  snake-charmers  appear  to  be  immune  against  certain 
species. 

These  individuals  often  extract  the  poison  fangs  preceding 
their  performances,  but  there  are  some  who  undoubtedly  go 
through  it  with  the  cobra  poison  fangs  intact.  It  is  asserted 
that  some  vaccinate  themselves  bv  allowing  }oung  cobras  to 
bite  them  from  time  to  time.  Nevertheless,  accidents  sometimes 
happen  and  the  best  of  them  may  die  in  the  calling.  They 
certainly  exercise  great  skill  in  the  attempt  to  avoid  being  bitten. 

The  repeated  inoculation  of  venom  heated  to  8o°C.  produces 
some  resistance  in  animals  (Calmette).  Calmette's  serum  is 
active  against  cobra-venom  but  not  against  Russell's  viper, 
Bungarus,  or  Echis.  The  varieties  of  pure  sera  now  in  the 
market  are  numerous  and  are  to  be  used  for  cases  of  poisoning 
by  snakes  whose  names  are  indicated  in  the  description  of  the 
serum. 

(i)  Lamb's  pura  Xaja  tripudians  Merrem  serum. 
{2)  Lamb's  pura  Vipera  russelli  Shaw  serum. 
(3)  Tidswell's  pura  Notechis  scutatus  serum. 
C4)   Xoguclii's  pura  crotalus  serum. 


THE    TREATMENT    OF   SNAKE   BITE  445 

(5)  Noguchis  pura  Ancistroden  piscivorus  serum. 

(6)  Brazil's  pura  Crotalus  horridus  serum. 

(7)  Kitajima's  pura  Lachesis  Hallow  serum. 

(8)  Polyvalent  sera,  not  very  efficacious. 

Sera  can  be  so  made  as  to  remain  unimpaired  for  two  years  in 
all  climates.  They  can  be  given  prophylactically  and  curatively 
in  the  latter  instance  as  soon  as  the  species  of  snake  is  known 
or  suspected.  They  all  degenerate  rapidly  if  not  kept  in  a  dark 
cool  place.  They  must  be  used  in  large  doses,  Calmette  recom- 
mends 10  c.c.  subcutaneously  and  Martin,  Lamb,  100  c.c. 
intravenously.  There  is  a  wide  difiference  of  opinion  on  the 
dosage  question. 

(3)  To  aid  the  Excretion  of  the  Venom. 

The  kidney  is  said  to  excrete  most  of  the  venom  that  leaves  the 
body.  The  urine  of  a  poisoned  dog  is  said  to  have  killed  an  injected 
pigeon  in  twenty-four  hours. 

The  salivary  and  mammary  glands  also  play  some  small  part  in 
its  excretion.  The  condition  is  usually  so  acute  and  the  toxin  so 
destructive  that  there  is  but  little  opportunity  for  stimulating  the 
excretorv  organs. 

Salines  can  be  given  and  sweating  encouraged. 

(4)  To  iVIaintain  the  Strength  of  the  Patient. 

Strychnine  can  be  given  when  there  is  but  little  neurotoxin  in  the 
venom. 

Caffeine  and  adrenalin   injections  are   indicated. 

Salines  intravenously,  per  rectum  and  subcutaneously. 

Ammonia  and  ether  are  good. 

Apply  a  binder  to  the  abdomen  and  bandages  to  the  legs. 

Warmth  is  necessary. 

Energetic  movements  are  exhausting. 

Alcohol  as  a  rule  reduces  the  activity  of  the  antivenene. 

(5)  Symptomatic  Treatment. 

Give  calcium  lactate  in  large  doses  for  viper  venom. 
Bromides,  chloral  hydrate  and  chloroform  may  be  useful  for  rest- 
lessness, spasms  and  convulsions. 
Morphia  for  the  pain. 
Artificial  respiration  when  such  is  failing. 

(6)  To  Prevent  Secondary  Infection. 

Treat  on  antiseptic  lines  with  much  care  and  patience,  especially  in 
viper  cases. 

Acton  and  Knowles  in  working  on  this  subject  tell  us  :  — 
That  ligature  is  efficacious. 


446  DISEASES    DUE    TO    VENOUS    AND    POISONS 

Simple   amputation   of   the   digit   immediate!}'   when  the   toe  or 
finger  only  is  bitten. 

Local  injections  of  lo  c.c.  of  5  per  cent,  solutions  of  potassium, 
zinc    or    calcium    permanganate    are    good.      Or   of    iodine    tri- 
chloride or  of  gold  chloride,  which  is  the  best  of  all. 
Local  injections  must  be  given  at  once  and  after  ligature,  to  be 
of  any  use.     They  do  not  afifect  that  poison  already  absorbed. 
Incision   and   excision    of    the    wound,    electrolysis,    irradiation^ 
cauterization,  bleeding,  perfusion,  &c.,  are  all  ineffective. 
Intravenous  injections  of  potassium   permanganate  are   useless 
and  dangerous. 
The    neurotoxin    of    cobra    venom    is    absorbed    quickly    but    fixed 
slowly  and  not  firmly. 

The  venom  of  Russell's  viper  is  absorbed  slowly  and  fixed  firmly, 
Hence  delay  in  giving  antivenene  is  more  dangerous  in  viper  than 
cobra  bite.  1 

The   union    of  venom    and    antivenene   in    vitro    is    instantaneous^ 
hence  in  cobra  bite  half-hour  doses  are  almost  as  good  as  one  whole 
dose  at  once,   but  for  viper  bite  give  the  whole  dose  at  once  in  one 
dose,  50-100  c.c.  intravenously  or  100-200  c.c.  intraperitoneally. 
Acton   and   Knowles  conclude  :  — 

(i)  Apply  a  firm  ligature  immediately. 

(2)  Impregnate  the  whole  area   of  the  bite  with  a   hypodermic 
injection  of  a  strong  solution  of  gold  chloride. 

(3)  Inject  from   100  to  200  c.c.  of  antivenene  intravenously,   if 
the  biting  snake   is   suspected   to   be  a  cobra   or   Russell's 
viper. 

If  symptoms  of  venom  intoxication  come  on,  further  and 
even  larger  doses  of  antivenene  should  be  given  intra- 
venously. 

With  sera  concentrated  ten   times,   a  dose  of  20  to  60  c.c. 
should  save  every  case  of  cobra  bite. 
Prophylactic  Measures. 

When  crossing  jungle  or  grassy  districts  wear  strong  boots  and 
puttees  or  leggings. 

Carry  a  stick  when  travelling;  it  is  often  useful  in  striking  down 
snakes. 

When  doubtful  look  upon  all  snakes  as  dangerous. 

Carry  a  lantern  when  walking  after  dark. 

Always  carry  a  little  permanganate  in  case  of  need. 

Never  sleep  upon  the  ground. 

Cover  drain  pipes  with  gratings. 

Keep  the  gardens  free  from  long  grass. 


VENOMOUS    AND    POISONOUS    FISHES  447 

Enemies  of  snakes  should  be  encouraged.  The  Mussurana,  or 
Oxyrhopus  cloeha,  is  a  harmless  colubrine,  which  is  said  to  feed 
exclusively  on  other  snakes  and  to  be  addicted  particularly  to  the 
venomous  kinds,  overcoming  and  swallowing  them  in  a  most  heroic 
manner.  This  would  probably  be  a  good  variety  for  the  preparation 
of  sera  (Alcock). 

VENOMOUS  AND  POISONOUS  FISHES. 

Tropical  and  temperate  seas  abound  in  poisonous  fishes  about 
which  little  is  known.  Pending  further  knowledge  we  classify  them 
thus  :  — 

(i)  Fishes  which  poison  by  their  bite. 

(2)  Fishes  which  poison  by  their  spines  connected  with  poison 
glands. 

(3)  Fishes  which  poison  after  their  consumption  as  food. 

The  former  two  are  venomous,  but  their  flesh  can  be  eaten  with 
impunity.  The  latter  is  poisonous  and  produces  its  effects  when  eaten,, 
e.g.,  lamprey. 

The  genus  Cattus  is  only  venomous  during  the  spawning  season. 

All  these  venoms  are  alike  in  kind,  but  differ  in  degree. 

The  effects  are  :  local  pain,  swelling,  suppuration,  spreading 
gangrene,   excitation,   insensibility  and  paralysis. 

The  treatment  is  for  snake-bite,  with  the  exception  of  the  anti- 
venene. 

(1)  Fishes  which  poison  by  their  Bite. 

The  tvpe  is  the  genus  Alura^na.  All  have  powerful  teeth.  They 
abound  in  the  Tropical  Atlantic  and  Mediterranean.  The  poison 
pouch,  capable  of  holding  up  to  h  c.c,  lies  above  the  covering  of  the 
palate,  and  is  lined  bv  epithelial  cells.  There  are  three  or  four  strong 
curved  conical  teeth  with  an  anterior  convexity.  These  teeth  are 
enclosed  in  a  sheath  formed  by  the  mucosa  of  the  palate.  The  poison 
collects  between  the  teeth  and  flows  down  into  the  wound. 

(2)  Fishes  which  poison  by  their  Spines  connected  to  Poison  Glands. 

The  poison  glands  are  generally  placed  at  the  base  of  the  dorsal 
or  anal  fins  or  under  spines  on  the  operculum. 

The  glands  communicate  with  one  or  more  rays  of  fins. 

The  barbs  may  be  :  — 

Grooved,  the  muco-membranous  sheath  converting  this  into  a 
canal  which  must  be  ruptured  before  excreting  externally. 

Canalised  by  channels  which  lead  to  apertures  near  its  tip.  If 
these  barbs  enter  the   skin   after  being  trodden    upon,    the  poison    is 


448  DISEASES    DUE    TO    VENOMS    AND    POISONS 

pressed  mechanically  into  ihe  wound.  'I'lic  ])ain  is  very  severe  and 
death  sometimes  resuUs.  Some  poisoncuis  fishes  cause  palpitation, 
fever,   delirium,   vomiting  and  syncope. 

(3)   Fishes  which  poison  after  their  Consumption  as  Food. 

The  most  dangerous  are  those  living  amongst  coral  reefs.  Those 
that  are  bright  coloured  are  known  to  cause  a  severe  reaction. 

There  are  several  species  belonging  to  the  genus  Tetrodon,  which 
are  sometimes  taken  by  the  Japanese  Avith  suicidal  intent. 

The    poison     symptoms    they     call     "  fuguismus."      The     poison 
appears  to  lie  in  the  ovaries  and  testicles,  which  contain  :  — 
Tetrodon ic  acid,  a  white  waxy  body. 
Tetrodin,  a  crystalline  base. 

Symptoms. — These  arise  within  three  to  fifteen  minutes  after 
eating  one  roe.  Gastric  unrest,  abdominal  pain,  burning  about  the 
fauces,  nausea,  severe  headache,  collapse  and  fainting;  paralysis  of 
the  heart  or  respiration  may  cause  death. 

The  mortality  is  high  (68  per  cent.). 

Treatment.^ — Evacuate  contents  of  stomacli  with  an  emetic. 

Give  stimulants  such  as  strychnine. 

VENOMOUS  TOADS  AND  SALAMANDERS. 

These  belong  to  the  Amphibia.  The  poisons  found  in  their  parotid 
glands  and  skin  are  :  — 

In  Toads,     (i)  Bufotalin,  an  acid. 

(2)  Bufonin,  a  neutral  body,  less  active  than  the  above. 
They  are  but  slightly   toxic   to   man,    irritating  the 
mucous  membrane,   and  especially  the  conjunctiva. 
Small  animals  are  severely  affected. 
In  Salamanders,     (i)  Salamandarin,  an  inorganic  base. 

(2)  Salamandaridin,   an  alkaloid. 
Neither  are  important. 

There  is  a  creamy  cutaneous  secretion,  toxic 
to  many  animals,  the  chemical  nature  of 
which  is  but  little  known. 

VENOMOUS  ANEMONES,  CORALS  AND  JELLY  FISHES. 

These  belong  to  the  CcTelenterata.  They  sting  by  means  of  a 
specialized  cell  (enidoblast)  which  encloses  a  nematocyst,  a  long,  hollow, 
spirally  coiled  filament,  lying  in  toxic  fluid.  When  irritated  the  cell 
sac  ruptures,  tlie  coil  filament  is  ejected,  making  a  small  wound  in  the 
animal  attacked,  and  thus  prepares  a  place  for  the  poison. 


TOXIC    HEUflNTHS  449 

Anemones  (Zoaiuharia). — Their  slings  cause  itching,  hLiining  and 
skin  eruptions.  Those  of  the  Mediterranean  affecting  the  naked 
sponge  divers  cause  a  febrile  attack  \\'\[h  thiisi,  pains  in  the  back  and 
limbs,  and  a  sk)Ughing  uk^er  k)cally.  iMshermen  use  them  for  poison- 
ing animals,  which  die  in  a  few  minutes. 
The  poisons  are  :  — 

(i)  Thalassin,      causing     redness,      congestion,      pruritis      and 

sneezing. 
(2)  Congestion,    more   toxic,    but    somewhat   antagonistic  to   the 
above . 
Apply  pure  fat  immediatelv  to  the  infected  site.     A  la}'er  of  grease 
over  the  skin  is  an  efificient  protection. 

Corals  (Millapora). — These  produce  local  pain  and  er^'thema, 
followed  by  papules,  ])usiules  and  descjuamation.  They  abound  in 
Malaya. 

Jelly  Fishes  (Traclninedusie). — Those  of  the  Mediterranean  cause 
local  redness,  swelling  and  urticaria.  Those  of  the  Tropics  are  more 
severe,  with  agonizing  pains  and  collapse. 

Give  stimidants  internalh'  and  dilute  ammonia  locallv. 

TOXIC  HELMINTHS. 

These,  such  as  Dibothriocephalus  latus,  Tccnia  saginata,  TcTnia 
ecchinococcus,  Ascarides  and  Ankvlostomes  are  dealt  A\ith  in  the 
section  "  Diseases  due  to  Helminths." 

VENOMOUS   SCORPIONS  AND   SPIDERS,   MITES   AND   TICKS. 

These  belong  to  the  Arachnida. 

Scorpions  (Scorpionidic)  abound  in  the  'J^'opics ;  are  much  dreaded. 

The  last  abdominal  segment  carries  a  curved  spine  which  in  attack- 
ing is  brought  forwards  over  the  body,  penetrating  the  victim's  skin, 
and  thus  making  a  wound  into  which  the  poison  is  injected.  On  either 
side  of  the- spine  is  an  opening  through  which  the  venom  is  discharged. 

The  toxins  of  different  species  dififer  in  kind  and  degree,  causing 
from  local  redness,  pain  and  swelling  in  Europe  to  severe  pain,  exten- 
sive swelling,  vomiting,  fainting,  muscular  cramps  and  death  in  the 
Tropics. 

Two  hundred  persons  are  said  to  die  annually  near  Durango  in 
Mexico  from  scorpion   stings. 

The  mortality  in  children  is  60  per  cent.  (Wilson).  Death  is  rare 
in  adults  because  of  the  greater  dilution  of  the  poison. 

In  Africa  stings  are  common,  but  death  is  rare. 


450  DISEASES    DUE    TO    VENOMS    AND    POISONS  . 

Scorpions  live  under  stones,  the  bark  of  trees,  in  sand  and  houses, 
which  latter  they  leave  at  dusk. 

They  seize  their  prey  with  their  large  six-jointed  pedipalpi,  hold- 
ing it  close  to  the  mouth  with  the  small  three-jointed  chelicera;,  bring- 
ing over  the  tail  to  sting  their  victim  if  necessary,  leaving  a  spine  in 
the  body  of  their  prey  until  the  poison  compressed  from  the  bilobed 
gland  along  the  duct  to  the  spinal  opening  has  acted  well. 

The  venom  causes  agglutination  of  red  cells  leading  to  thrombosis, 
haemorrhage  due  to  destruction  in  the  capillar}'  walls,  coagulation  and 
haemolysis  (Jousset  de  Bellesme).  It  also  contains  a  neurotoxin.  In 
some  respects  it  simulates  cobra  venom. 

Treat  as  for  medium  cases  of  snake  bite. 

For  the  pain  cocaine  can  be  injected  close  to  the  sting. 

Spiders  (Aranea). — These  grow  to  a  large  size  in  the  Tropics. 

All  genera  appear  to  be  toxic.  The  poison  gland  lies  at  the  basal 
joint  of  the  chelicera,  ensheathed  in  connective  tissue.  The  duct  runs 
forward  from  the  gland  to  the  distal  hook-shaped  joint,  upon  the  apex 
of  which  it  opens. 

The  effects  of  the  \enom  resemble  tliose  of  scorpions,  but  the 
general  symptoms  are  often  more  delayed  and  mav  be  of  a  tetanoid 
nature,  lasting  about  ten  days,  as  with  the  bite  of  Latrodectus  mactans. 

With  the  L.  scolis  of  New  Zealand  there  may  be  stiffness  of  the 
jaw  and  mouth,  difficulty  in  swallowing  and  speaking,  slow  pulse, 
slow  respiration,  and  death  or  recovery  in  about  six  weeks.  It  may 
be  confused  with  tetanus  at  first  and  tvphoid  later. 

The  Theridium  lugubre  may  cause  death  in  a  few  days.  Many 
.common  spiders  only  cause  a  local  reaction. 

The  Maoris  will  burn  down  the  hut  if  a  single  person  has  been 
bitten  in  order  to  destroy  the  spider.  They  believe  that  its  death  is 
absolutely  necessary   for  the  recovery  of  the  patient. 

Treat  as  for  scorpion  bites. 

Ticks  (Ixodia?). — These  cause  severe  effects  apart  from  their  being 
■  carriers  of  babesia  or  spirochceta. 

The  skin  is  pierced  by  the  teeth  on  the  digits  of  its  chelicera?.  The 
digit  is  moved  forwards  and  turned  outwards,  enlarging  the  wound, 
bringing  the  hypostome  into  position,  fixing  the  tick  bv  means  of  its 
curved  teeth.  The  salivary  gland  at  the  same  time  pours  a  toxic 
secretion  into  the  wound. 

The  Argas  persicus,  A.  reflexus,  Ornithodorus  moubala  cause  local 
pain  and  swelling.  The  O.  turirala  has  been  known  to  cause  general 
numbness  and  swelling,  vomiting,  diarrho-a,  urticaria,  profuse  sweat- 
ing, rigors,  fever  and  headache.     An  ulcer  mav  form  locallv. 


THE    VENOM    OF    CENTIPEDES  451 

The  Ixodes  ricinus  causes  a  severe  dermatitis,  a  pustular  eruption, 
also  abscesses  with  oedema.  Lymphangitis  and  fever  may  ensue  as 
a  complication. 

Remove  the  tick  by  covering  it  with  oil  so  that  it  cannot  breathe, 
then  it  will  detach  itself.  Cauterize  a  bad  wound.  Apply  sodi.  bicarb, 
solution  or  menthol  ointment. 

THE  YENOM  OF  CENTIPEDES. 

These  belong  to  the  order  Chilopoda. 

They  have  a  uniformly  segmented  trunk  with  a  pair  of  appendages 
to  each  of  its  twenty-one  segments.  They  live  under  stones  and  in 
shadv  places. 

The  appendages  of  the  first  segment  are  modified  to  form  jaws,  at 
the  base  of  which  the  poison  gland  lies.  The  duct  opens  at  the  apex 
of  the  claw;  thus  a  bite  shows  two  minute  wounds. 

The  venom  is  for  the  purpose  of  killing  insects  and  larv^.  It 
causes  itching  and  intense  pain  which  rapidly  affects  the  whole  limb. 
The  area  of  the  bite  turns  black  and  hmphangitis  may  ensue.  There 
may  be  vomiting,  irregular  pulse,  dizziness  and  headache.  Adults 
recover  in  twenty-four  hours,  some  children  die. 

Bathe  the  part  in  ammonia  solution,   i   in  5. 

Apply  fomentations.     Administer  opium. 

THE  YENOM  OF  LICE  AND  BUGS. 

The  local  itching  is  well  known.  Their  venom  is  of  little 
importance. 

The  part  they  play  in  the  dissemination  of  disease  is  discussed  in 
other  sections. 

THE  YENOM  OF  BEES  AND  WASPS. 

The  last  abdominal  segment  of  the  bee  contains  a  chitinous  sheath 
in  which  the  two  barbs  lie.  A  long,  bilobed,  tubular-coiled  poison 
gland  is  connected  by  a  duct  to  the  barbs  at  one  end  and  ramifies 
amongst  the  intestinal  contents  at  the  other.  One  part  of  the  poison 
gland  contains  an  acid,  the  other  an  alkaline  venom.  The  acid 
reaction  may  be  due  to  formic  acid.  The  peculiar  aromatic  smell  is 
due  to  volatile  substances.  The  toxin  is  noi  albuminous  and  is 
thought  to  have  an  organic  base.  The  amount  extracted  from  the 
hind  parts  of  two  bees  in  i  c.c.  of  water  will  kill  a  mouse  or  sparrow. 
The  eggs  of  bees,  like  those  of  the  viper  and  toad,  contain  the  specific 
venom. 


452  DISEASES    DUE    TO    VENOMS    AND    POISONS 

Bee  venom  contains  :  — 

(i)  Inflammatory  poisons,  perhaps  from  the  acid  gland. 

(2)  Neurotoxins,  convulsive  and  narcotic,  the  former  perhaps  from 
the  alkaline  gland. 

(3)  Hemolysins. 

Symptoms. — Bee  keepers  are  usually  partially  immune,  but  the 
immunity  is  temporary.     Local  inflammation  and  reaction  is  painfid. 

Sometimes  faintness,  vomiting,  cold  extremities  and  delirium 
appear. 

A  few  have  died  as  a  result.  CEdema  and  shock  may  be  marked. 
GEdema  of  the  glottis  is  not  uncommon  when  stings  are  about  the 
throat. 

The  svmptoms  usually  disappear  in  twenty-four  hours. 

The  dangers  are  with  children  and  old  people,  especially  when  the 
stings  are  numerous. 

Treatment. — Weak  solutions  of  ammonia  answer  w^ell.  Carbolic 
I  in  20  should  be  applied  at  once.  Str\'chnine,  ammonia  and  ether 
where  much  shock  is  present. 


THE  VENOM  OF  ANTS  AND  CATERPILLARS. 

Ants  (Formicidai). — Though  small,  ants  are  wonderfully  organized 
and  capable  of  controlling  the  animal  world  in  the  Tropics.  That 
which  is  dead  is  removed  by  them;  snakes  will  flee  at  their  approach,, 
and  man  does  not  relish  a  struggle  with  these  aggressive  creatures. 

Many  of  them  possess  a  poison  apparatus  analogous  to  that  of  bees. 

The  venom  contains  formic  acid. 

Symptoms. — Local  inflammation,  faintness,  shivering  and  tem- 
porary paralysis.  Dried  ants  are  used  by  natives  in  preparing  poison 
for  arrows.     Apply  ammonia  solution,  carbolic  (i   in  20),  or  camphor. 

Caterpillars  (Lepidoptera). — These  cause  a  skin  eruj)tion  and  faint- 
ness. 

The  tiger-moth  caterpillar  produces  a  very  painful  angry  eruption- 

The  caterpillar  of  Porthesia  chrysorrhoca  from  North  America 
causes  its  barbed  hairs  to  penetrate  the  skin  and  to  inject  a  venom 
that  causes  necrosis  of  the  epidermal  cells  and  the  formation  of  small 
vesicles.  Severe  urticarial  dermatitis  may  arise  due  to  contact,  the 
hairs  remaining  in  the  skin.  Some  people  are  more  sensitive  to  theni 
than  others. 

Clear  away  the  hairs  with  soda  bicarbonate  lotion  (2  per  cent.). 

Apply  ichthyol  ointment  (10  per  cent.). 


THE    J'ENOM    OF    MOSOCITOES  453 

THE  VENOM  OF  MOSQUITOES. 

The  females  only  (Ciilicid^e)  attack  man. 

The  mandibles  and  maxilla?  pierce  and  cut  like  spear  points  and 
saws. 

An  irritating  substance  is  injected  from  the  salivary  glands,  the 
nature  of  which  has  not  been  ascertained.  The  part  itches,  becomes 
red,  a  weal  may  result;  secondary  infection  is  a  common  occurrence 
as  a  result  of  scratching  them. 

VENOMOUS  BEETLES,  SNAKES  AND  LIZARDS. 

These  beetles  (Coleoptera)  and  their  larvae  irritate  by  means  of  stiff 
hairs.  Pain,  inflammation  and  sloughing  results.  In  the  Solomon 
Islands  there  is  a  venomous  snake  of  unknown  species  which  possesses 
tubular  barbed  teeth.  These  are  connected  with  a  poison  gland  which 
sometimes  causes  severe  wounds  in  man. 

There  are  two  lizards  celebrated  for  their  poisonous  bites,  the 
Trachyderma  horribum  of  Mexico  and  the  Heloderma  suspectum  of 
the  United  States.  The  former  when  irritated  discharges  a  white, 
gelatinous  salivary  fluid  from  its  mouth  which  is  asserted  to  produce 
toxic  symptoms.     The  creature  may  reach  to  nearly  live  feet  in  length. 

The  poison  of  the  latter  is  passed  along  grooved  teeth.  Its  effects 
are  similar  to  an  average  amount  of  cobra  venom,  and  should  be 
treated  as  for  that  condition. 

POISONS   TAKEN   ACCIDENTALLY   BY   MAN. 

Poisoning  by  fish  has  been  described. 

Sitotoxismus  is  a  term  given  to  vegetable  food  poisoning. 

Ergotism  is  not  important  in  the  Tropics. 

Lathyrismus  is  an  intoxication  caused  by  the  ingestion  of  Lathvrus 
satireus  and  similar  species.  It  exists  in  India.  People  who  eat 
vetches  in  time  of  famine  are  liable  to  be  attacked.  The  disease 
appears  to  be  due  to  eating  bread  composed  of  flour  of  the  seeds  of 
Lathyrus  belonging  to  the   Order  LeguminoSce. 

If  poverty  causes  an  outbreak  it  is  usuallv  endemic. 

If  famines  cause  an  outbreak  it  is  usually  epidemic. 

Many  toxic  substances  have  been  separated. 

The  incubation  is  not  known. 

The  onset  is  insidious,  pain  in  the  back,  weakness  in  the  legs  and 
spastic  paraplegia  manifest  themselves.  Girdle  sensations,  dragging 
feet  and  wasting  of  the  muscles  soon  follow.  The  deep  reflexes  are 
increased,  ankle  clonus  is  present,  muscular  electrical  reaction  dimin- 
ished,   but    the   reaction    of  degeneration    is   absent.     Incontinence    of 

29 


454  DISEASES    DUE    TO    I'ENOMS    AND    POISONS 

urine  and  impotence  are  common.  Tlie  mind  is  normal.  There  is  no 
gang-rene  as  in  ergotism  and  no  dropsy  or  heart  symptoms  as  in 
beriberi,  (iive  some  food,  warm  clothing,  bromides  and  counter 
irritants  to  the  spine. 

Lolismus  is  an  intoxication  due  to  the  ingestion  in  bread  of  the 
seeds  of  Loliuni  temulentum.  It  is  present  in  some  parts  of  India  and 
Europe.  There  are  giddiness,  trembling  of  arms,  legs,  and  tongue, 
impairment  of  vision,  dilated  pupils,  prostration  and  vomiting. 

It  is  seldom  fatal. 

Give  a  castor  oil  purge  and  stimulants. 

Paspalismus This   is   the   result   of   eating  bread    made   from   the 

seeds  of  Paspalum  scrobiculatum.     Sometimes  fatal. 
Symptoms  and  treatment  as  above. 
Fungi  are  said  to  play  some  part  in  it»o  production. 

Atripliasmus — A  similar  disease  confined  to  China. 

The  poor  eat  the  seeds  of  Atriplex  serrata,  which  grows  wild  in 
the  courts,  gardens  and  on  the  walls  of  Pekin.  A  parasite  eaten  with 
the  weed  may  be  the  cause  of  the  disease. 

The  s\-mptoms  begin  ten  to  twenty-four  hours  after  its  con- 
sumption. 

The  finger-tips  and  the  dorsum  of  the  hands  become  painful, 
swollen,   c\anosed  and  cold.     This  condition  spreads  to  the  forearm. 

The  face  and  eyelids  itch  and  become  swollen,  the  nose  is  cyanosed 
and  cold.  Sensibility  to  touch  is  diminished,  to  heat  increased,  bullae 
and  ulcers  may  appear  on  these  parts,  and  gangrenous  patches  are 
possible.     The  general  health  is  but  little  affected. 

The  treatment  is  symptomatic.  With  Raynaud's  disease  there  is 
no  swelling. 

Tapioca  is  obtained  from  the  cassava  root  (Manihot  utilissima). 
The  bitter  variety  contains  hydrocyanic  acid  in  its  milky  juice,  and  is 
poisonous  until  it  is  roasted,  when  the  volatile  acid  is  driven  out.  The 
juice  should  be  expressed  and  the  root  cooked  before  eating. 

Nutmegs  are  poisonous  if  taken  in  large  doses. 

Castor  Oil  Seeds  (Euphorbiacea?)  cause  burning  of  the  throat  and 
abdomen,  vomiting  and  collapse.     There  may  be  diarrhoea. 

These  seeds  will  kill  in  about  fort^'-six  hours. 

Give  emetics,   stimulants  and  morphia. 

Manchineel  Tree  Fruit  (Hippomane  mancinella,  Euphorbiaceas).— 
These  fruits  look  very  like  apples  and  have  a  delightful  fragrance. 

They  are  common  on  the  Grenadine  Islands,  and  sailors  have  met 
I  heir  deaths  mistaking  the  fruit  for  that  of  apples.  There  is  gastro- 
intestinal   inflammation,   dilated  pupils,   bullae  on  the  skin. 


ACKEE    POISONING  455 

Kreotoximus  is  a  gastro-intestinal  disturbance  which  may  simulate 
cholera,  and  is  produced  by  the  ingestion  of  semi-decomposed  animal 
foods.  The  bacillus  of  Gartner  and  the  paratyphoid  bacillus  give  rise 
to  ptomaines  causing  the  symptoms. 

Emetics,  purgatives,  stimulants  and  salines  are  indicated,  with  a 
course  later  of  intestinal  antiseptics  as  salol  or  calomel. 

ACKEE   POISONING. 

The  Vomiting  Sickness  of  Jamaica.     (After  Scott.) 

DEFINITION. 

A  localized,  epidemic,  acute  toxaemia  probably  due  to  the  ingestion 
and  absorption  of  toxins  from  the  ackee  fruit,  Blighia  sapida. 

It  occurs  in  young  adults  and  children  in  Jamaica  and  is  accom- 
panied by  a  heavy  mortality. 

iETIOLOGY. 

The  disease,  whicii  is  prevalent  in  the  cooler  months,  November 
to  March  or  April,  seems  to  be  caused  by  the  ingestion  of  the  ackee 
fruit  that  has  fallen  unripe  from  the  tree.  The  epidemic  nature  of  the 
disease  coincides  with  the  main  ackee  season. 

Its  localized  peculiarity  may  be  due  to  this  fruit  not  being  plenti- 
fully grown  elsewhere,  or  that  it  is  not  in  other  places  used  as  a  food. 

If  the  dose  taken  is  small  and  vomiting  takes  place  at  once  the 
poison  is  rejected  and  recovery  may  follow. 

The  children  are  chiefly  affected  because  they  are  given  "  pot- 
water  "  in  which  the  ackee  fruit  has  been  boiled,  a  water  solution  of 
the  toxin  being  most  dangerous;  also  it  is  due  to  the  children,  more 
than  adults,  picking  up  the  fallen  unripe  fruit  and  eating  it. 

The  fruit  is  poisonous  if  it  is  picked  up  from  a  decayed,  bruised, 
or  broken  branch;  if  forced  open  and  not  opened  naturally  on  the 
tree  and  other  conditions. 

SYMPTOlViATOLOGY. 

These  can  be  summed  up  under  three  heads  :  — 

(i)  Vomiting. — The  patient,  almost  invariably  a  child,  has  dis- 
comfort or  pain  in  the  stomach.  It  vomits  once  or  twice  or  four  times. 
Recovery  may  follow  if  all  the  toxin  is  rejected,  or,  on  the  contrary,, 
the  child  may  be  fairly  well  or  sleep,  if  at  night,  for  several  hours.- 
Then  there  may  be  another  attack  of  vomiting,  probably  cerebral  in 
origin,  of  frothy  mucus,  followed  by  watery  or  bile-stained  fluid.  A 
few  cases  do  not  vomit  at  all. 

The    former    is    known    as    Initial    vomiting,    and    the    latter    as. 


456  DISEASES    DUE    TO    VENOMS    AND    POISONS 

Secondary  vomiling.     \'eiy  few  indeed  recover  who  reach  the  second 
stage. 

(2)  Convulsions. — In  a  few  minnles  there  are  convulsions,  var}-ing 
in  given  cases  from  twitching  movements  to  definite  massive  convul- 
sions; single  clonic  muscular  spasms  to  marked  epileptoid  clonic 
contractions. 

(3)  Coma. — The  coma  is  deep  and  fatal.  The  conjunctival  reflex 
is  absent. 

The  temperature  is  usually  normal  or  up  to  101°  F.  The  pulse 
90-100.     The  respirations  26-30. 

There  is  no  delirium. 

Recovery  or  death  is  very  rapid,  even  in  one  hour. 
.     The  average  time  from  the  onset  of  symptoms  to  death  is  i2"j  hours. 

The  final  picture  is  probably  due  to  rapid  absorption  of  toxins  from 
the  empty  stomach. 

PATHOLOGY. 

There  is  hypera^mia  of  most  of  the  organs,  including  the  meninges, 
with  oedema  of  the  suppurating  tissue. 

There  are  small  extravasations  in  the  kidneys,  adrenals,  Ivmpli 
glands,  spleen  and  lungs. 

Microbiotic  changes  in  the  kidney  tubules,  pancreas  and  liver. 

Fatty  changes  in  many  organs,  especially  the  liver,  kidneys, 
pancreatic  cells,  heart  muscle,  and  the  large  Betz  cells  in  the  brain. 

MORTALITY. 

80-90  per  cent,  of  those  attacked  die. 

PROPHYLAXIS. 

To  prohibit  the  fruits  of  Blighia  sapida  to  be  used  as  food. 
To  educate  the  people  as  to  its  dangers. 

If  not  sufficient,  then  to  request  powers  to  destroy  all  the  trees  in 
the  island. 

POISONS  USED  FOR  POISON   ORDEALS,   FIGHTING,   FISHING, 

HUNTING. 

The  poison  ordeal  once  prevalent  in  England  is  common  in  Africa. 

The  local  witch  doctor  prepares  a  mixture  more  or  less  poisonous, 
which  is  given  to  a  person  "suspected  "  of  some  crime.  The  ingre- 
dients of  many  of  these  preparations  are  unknown,  but  poisons  from 
the  Loganiaceal,  Apocyanaceal,  LeguminosiE  and  Salanaceal  are 
commonly  used.  In  West  Africa  the  sliced  root  bark  of  Strychnos 
icaja    or    decoction    of    strophanthus    is    used.      If    after    drinking    a 


POISONS    USED    FOR    POISOAf    ORDEALS  457 

decoction  the  victim  can  jump  over  a  stick  or  micturate  upon  a  banana 
leaf  he  is  declared  innocent.  This  is  seldom  possible.  The  Calabar 
bean,  Physostigma  venenosum  (Leguminos^e)  is  often  used.  If  the 
victim  vomits  he  is  innocent,  if  not  he  is  guilty  and  dies. 

Arrow  poisons  varv  with  the  different  countries  in  which  they  are 
employed.  Thev  are  usually  only  known  to  the  witch  doctors,  chiefs 
and  fetish  priests.  Snake  venom,  scorpions,  spiders  and  beetles  pulped 
and  well  mixed  with  vegetable  poisons  are  used.  Vegetable  poisons 
are  important. 

Some  act  upon  the  heart  and  muscles  like  digitalis. 

peripheral  nerve  endings  like  curari. 
,,  nervous    system    and    heart    like    aconite    and 

strychnine. 
,,  ,,  system  like  snake  venoms. 

To  treat  an  arrow  wound,  apply  a  tourniquet  to  the  limb,  proximal 
to  the  wound.  Remove  the  arrow  by  passing  a  hollow  tube  (bamboo) 
over  the  barb  and  withdrawing  it,  or  folding  the  skin  as  close  to  the 
point  as  possible,  push  the  barb  through,  divide  the  shaft,  withdraw 
the  barbed  end  forwards  and  the  feathered  end  backwards.  Cup  and 
wash  the  wound  with  strong  permanganate.  Give  stimulants  generally 
and  fomentations  locally.  Strophanthus  is  much  used  in  Central 
Africa  (Livingstone). 

It  causes  death  in  from  ten  to  fifteent  minutes. 

Fish  poisons  are  used  all  over  the  world  by  natives.  The  bark  and 
leaves  of  trees  and  shrubs  are  thrown  into  the  water.  The  fish  are 
rendered  unconscious  by  the  poison,  and,  floating  to  the  surface,  are 
readilv  captured.  The  varieties  are  numerous.  Some  of  the  active 
principles  are  strychnine,  hvdrocyanic  acid,  piscidin,  a  non-nitrogenous 
substance  called  derrid  and  pachyrhizid. 

Denis  root  will  kill  fish  in  a  dilution  of  i   in  25,000  of  water,  and 
Derrid  ,,  ,,  ,,  i  in  5,000,000  of  water. 

Poisons  for  animals  are:  The  root  of  Aram  montanum  for  tigers  in 

India. 
Aconite  for  elephants  in  India. 
Tylophora    fasciculata,     &c.,     for    rats    in 

Africa. 
Dianella  nemorosa  L.  for  rats  in  Malacca. 


458  DISEASES  OF  THE  SKIN 


SECTIOxN    VI. 

DISEASES  OF  THE  SKIN. 

INTRODUCTION. 

The  skin  diseases  of  temperate  climates  are  prevalent  in  the  Tropics 
with  few  exceptions,  but  because  of  differently  coloured  skins  their 
diagnosis  is  often  somewhat  difficult,  and  clinical  characters  alone  are 
insufficient  for  their  discrimination. 

The  skins  of  Tropical  races  differ  from  those  of  temperate  climates 
in  thickness,  pigmentation,  sebum,  sweat  and  hair. 

The  skin  of  the  African  negro,  and  to  a  less  extent  that  of  the 
Indian  races,  is  somewhat  thicker  than  that  of  the  European,  thus 
affording  a  good  protection  for  his  poorly  clad  body  in  the  rough-and- 
tumble  life  he  lives. 

The  pigmentation  is  marked  and  characteristic  of  tropical  natives. 
It  is  present  at  birth,  giving  the  baby  a  muddy  appearance,  then 
darkens  rapidly  during  the  first  few  weeks,  and  slowly  until  puberty. 
Perhaps  this  is  a  provision  of  Providence  for  protecting  them  against 
the  sun's  rays. 

The  sebaceous  glands  are  more  highly  developed,  the  secretion 
giving  a  more  glossy  appearance  to  the  skin  and  a  characteristic  odour 
so  readily  noticed  by  the  new-comer  to  the  Tropics.  This  excess  of 
sebum  is  also  protective,  as  fat  is  a  bad  conductor  of  heat. 

The  secretion  of  sweat  is  also  in  excess.  It  evaporates  readily  and 
keeps  the  skin  cool.  Profuse  sweating  may  also  be  the  result  of  nerve 
exhaustion  or  of  a  blood  toxaemia  calling  for  the  elimination  of  toxins. 

The  hair  is  poorly  developed.  It  is  smooth  in  Indian  races  and 
curly  in  African  natives,  the  woolly  nature  being  due  to  the  spiral  hair 
follicles  of  the  scalp.  Hair  growths  about  the  face  are,  as  a  rule,  thin 
an-d  shaggy.     The  lanugo  hair  is  but  poorly  developed. 

Pathological  conditions  of  the  skin  undoubtedly  have  predisposing 
factors  in  the  climatic  influences  of  the  Tropics. 

A  hot  dry  climate  causes  rapid  evaporation  of  sweat  and  a  dry 
*' cracked  "  skin,  easily  injured,  while  a  moist  heat  causes  damp 
sebaceous  deposits  favourable  for  the  development  of  skin  parasites 
and  a  softening  of  the  skin  which  facilitates  disease. 


ACANTHOKERA  TO  DERM  I A  459 

The  sun's  rays  cause  hypercemia  and  heatstrokes,  the  former  lead- 
ing up  to  subcutaneous  oedema  and  vesication  in  those  frec^uently 
exposed,  resuhing  in  a  thickening  of  the  skin  and  a  deposition  of 
pigment.  This  condition  is  seen  in  pellagrous  patients.  Cold  cream 
and  vaseline  are  good  for  sunburn,  lead  and  opium  lotions  are  sooth- 
ing. Helmets  made  of  pith  or  rubber  so  as  to  protect  the  head  and 
the  nape  of  the  neck  should  be  worn  from  sunrise  to  sunset  as  a  routine 
thing. 

Flannel  and  cholera  belts  are  often  irritating  and  predispose  to 
prickly  heat.  Silk  or  silk  and  cotton  clothing  next  to  the  skin  is 
efficacious. 

Alcohol  is  often  taken  owing  to  increased  thirst  and  to  a  feeling  of 
exhaustion  so  common  at  the  close  of  the  day.  This  causes  increased 
perspiration  and  predisposes  to  prickly  heat;  it  is  not  necessary  and 
should  be  avoided;  in  any  case  moderation  is  essential. 

A  daily  tepid  bath  is  necessary  for  skin  cleansing.  All  attempts  at 
the  classification  of  skin  diseases  are  at  present  provisional  and  at  the 
best  incomplete.  Dermatologists  are  still  taking  certain  varieties  from 
the  "  Eczema  "  group  and  giving  to  them  a  definite  place  in  the 
dermatological  "  pigeon-hole." 

We  feel  that  it  will  suit  our  purpose  best  to  deal  with  the  most 
prevalent  tropical   skin  diseases  alphabetically. 

ACANTHOKERATODERMIA. 

This  is  a  term  used  by  Chalmers  to  include  "  liyperkeratoses  " 
accompanied  by  "acanthosis." 

There  are  thickened  areas  of  epidermis  which  may  break  down  or 
become  fissured,  affecting  the  soles  and  palms. 

This  condition  is  accompanied  by  hyperkeratosis  subungualis. 

The  thick  horny  layer  is  largely  composed  of  cornified  and  modified 
prickle  cells. 

ACARIASIS. 

This  is  an  eruption  affecting  the  whole  body  caused  by  the 
Pediculoides  ventricosus,  the  "  Acarien  "  of  barley.  The  eruption 
may  simulate  urticaria  or  scabies,  and  is  characterized  by  papules  of 
the  face,  neck,  trunk  and  limbs,  or  sometimes  bv  urticarial  patches 
with  a  small  vesicle  in  the  centre. 

The  itching  is  intense  and  lasts  longer  than  the  eruption. 

The  symptoms  may  come  on  a  few  hours  after  handling  infected 
barley,  but  it  clears  up  itself  within  twelve  hours  if  not  scratched. 

Swelling  of  the  neck  and  face  is  rare. 

The  condition  has  been  seen  in  Algeria  (Sergent  and  Alarv). 

Sulphur  preparations  are  indicated. 


46o  DISEASES   OE   THE  SKIN 

ACNITIS. 

An  uncommon  papulo-puslular  eruption,  probabh-  caused  by  a 
poison  g-enerated  under  the  influence  of  sunlight  b\-  cutaneous  cells 
sensitized  to  the  tubercular  \irus,  and  attacked  bv  the  products  of  an 
intestinal  aulo-inoculation,  the  whole  process  being  anaphylactic  in 
nature  (Chalmers  and  Martin). 

The  papules  appear  about  the  head,  neck,  face,  dorsum  of  the 
hands  and  on  parts  exposed  to  light. 

71ie  condition  has  been  differentiated  from  Acne  vulgaris,  Acne 
varioliformis.  Lupus  vulgaris,  Erythema  induratum,  Dermatitis  nodosa 
rubra  and  Drug  eruptions. 

Von  Pir(|uet's  reaction  was  positive  in  Chalmers's  case. 

Salol,   salines  and  calomel  are  indicated. 

There  should  be  early  protection  against  auto-intoxication. 

ACRODERMATOSIS. 

This  is  probably  an  impetiginous  afifection  of  the  hands  and  feet 
due  to  staphylococci  or  streptococci,  as  seen  in  poor  children  living 
under  insanitary  conditions. 

ACRODERMATITIS   CHRONICA   ATROPHICANS. 

A  general  condition  of  inflammation  and  infiltration  of  the  skin 
followed  by  atrophy.  Its  aetiology  is  unknown.  It  differs  from 
idiopathic  atrophy  by  the  inflammatory  stage. 

ACRODERMATITIS  VESICULOSA  TROPICA. 

A  rare  disease  of  unkmnvn  causation.  Both  hands  are  afTected, 
the  skin  is  glossy  and  tense,  contains  small  vesicles  with  clear  fluid. 
The  fingers  taper,  there  is  pain  and  hypenesthesia.  The  hands  are 
useless  for  work.  The  condition  lasts  from  several  months  to  several 
years  and  may  clear  up  spontaneously. 

Give  ichlhyol,  internally,  3  grains,  t.d.s.,  and  externally  as  an 
ointment,  2-5  per  cent. 

ALBINISM. 

A  partial  or  complete  congenital  absence  of  pigment  in  the  skin, 
iris,  choroid  and  hair.  The'  condition  is  generally  hereditary  and  is 
more  common  in  coloured  peoples.  It  is  endemic  in  some  tropical 
regions.  There  is  intolerance  to  light,  and  hence  contracted  pupils. 
The  hair  is  white,  fine  and  silky;  the  iris  rose-coloured,  and  the  pupil 
appears  to  be  a  pinkish-red. 


ANGIO-FIBROMA    CONTAGIOSl'M    TROPICUM  461 

ANGIO-FIBROMA  CONTAGIOSUM  TROPICUM. 

A  disorder  of  unknown  causation  found  only  in  Southern  Brazil. 

After  an  incubation  of  fifteen  to  twenty-five  days  there  is  an 
eruption  of  red  papules  developing  rapidly  to  the  size  of  peas  or 
almonds. 

The  face,  neck,  axilke  and  genitals  are  most  cimnionly  affected, 
also  the  mucosae.  The  papules  bleed  readily.  There  is  no  fever. 
They  clear  up  spontaneously  without  any  scar. 

ASPERGILLOSIS. 

A  chronic  fungus  affection  of  the  hairs  of  the  beard  and  moustache 
bv  the  Aspergillus  barbae.  Penicillium  barbae  is  also  commonly  found 
at  the  same  time. 

Shave  the  hair  and  use  turpentine,  followed  by  carbolic,  tar,  or 
sulphur  soap. 

BARCOO  ROT. 

This  is  a  condition  closelv  allied  to,  if  not  identical  with,  the 
"  \'eldt  sore  "  of  Africa.  There  are  blebs  in  an  inflammatory  area 
containing  thin  pus,  which  arise  on  the  backs  of  the  hands  and  wrists 
which  develop  into  shallow  ulcers.  There  is  a  preponderance  of 
staphylococci  in  the  blebs  and  earlv  afifecled  hairs. 

Exposure  and  exhaustion  predispose. 

Epilation  of  the  affected  hairs  and  ordinary-  antiseptic  treatment 
under  good  conditions  will  soon  clear  up  the  condition. 

BIOTRIPSIS   (Life-wear). 

A  general   atrophic  condition   due  to  old  age  (idiopathic  a.lrophy). 

BLASTOMYCOSIS. 

Blastomvcetic  dermatitis  is  a  chronic  (five  to  ten  years)  inflam- 
matory disease  of  fungus  origin  caused  by  the  genera,  Saccharomyces, 
Cryptococcus,  Coccidiodides  and  Monilia. 

SYMPTOMATOLOGY. 

A  reddish  maculo-papule  appears,  becomes  infected  and  suppurates. 

The  papules  become  ulcerated  nodules,  which  spread  in  extent  and 
depth,  producing  a  raw  and  ulcerated  mass.  The  dorsum  of  the  hand 
and  the  front  of  the  leg  are  usually  attacked  first,  but  any  part  may  be 
affected.  The  alse  nasi  and  the  lips  mav  be  destroyed.  The  disease 
is  not  confined  to  the  skin,  but  mav  affect  the  internal  organs. 

The  disease  may  last  for  A-ears  and  then  clear  up  spontaneously, 
leaving  a  soft  smooth  scar. 

There  is  very  little  pain  and  the  lymphatic  glands  are  not  enlarged. 
On  close  examination  numerous  miliary  abscesses  are  seen  in  which 
the  parasites,  epithelioid  and  giant  cells  can  be  found. 


462  DISEASES   OE  THE  SKIN 

DIAGNOSIS. 

It  closely  resembles  tuberculosis  of  the  skin,  and  may  be  mistaken 
for  the  vegetating  forms  of  syphilis. 

The  diagnosis  rests  upon  finding  the  fungi  in  the  minute  abscesses. 

TREATMENT. 

Potassium  iodides  in  large  doses,  i  gramme,  t.d.s.,  and  increased 
until  the  disease  disappears. 

Rontgen  rays,  where  available,  can  be  applied  with  benefit. 
Local  applications  of  sublimate  and  iodine  tincture  are  useful. 
For  visceral  and  general  infection  there  is  no  successful  treatment. 

BOILS. 

Tropical  boils  are  very  common,  and  are  usually  severe  and 
resistant.     Auto-inoculation  should  be  closely  guarded  against. 

Conditions  of  lowered  resistance  and  diabetes  predispose  to  them, 
but  the  immediate  agents  are  pyogenic  organisms,  chiefly  the 
siaphykjcoccus. 

TREATMENT. 

The  condition  frecjuently  rec^uires  that  the  patient  shall  be  invalided 
in  order  to  raise  his  powers  of  resistance. 

Treat  any  constitutional  disorder  and  avoid  poulticing. 

Touch  new  boils  with  tincture  of  iodine,  wash  old  ones  with  sub- 
limate. One  drop  of  pure  carbolic  acid  in  a  small  drilled  hole  will 
often  abort  the  abscess. 

Prepare  and  administer  an  autogenous  vaccine. 

Avoid  opening  boils  early. 

BOTRYOMYCOSIS  HOMINIS. 

A  condition  of  f ungating  granulomas  occurring  as  a  sequel  to 
wounds  which  have  been  infected  with  cocci.  They  grow  slowly  until 
about  the  size  of  a  cherry  and  are  ]3edunculated.  They  occur  in 
clusters.  Some  authorities  affirm  that  the  condition  is  caused  by 
Botr}-()m}ces  ascoformans,  others  blame  an  amoeba-like  organism. 

BROMIDROSIS. 

Perhaps  each  individual  has  his  o^\■n  peculiar  offensive  odour  when 
perspiring  excessively,  probablv  due  to  the  increased  sebaceous  matter 
secreted.  Lack  of  cleanliness  always  makes  the  condition  worse,  but 
in  some  cases  marked  cleanliness  A\ill  not  remove  the  odour  completely. 
Some  of  the  great  variety  of  scents  may  be  used  to  counteract  it.  The 
clothing  should  be  changed  frequently. 

Alcohol  should  be  avoided. 


CH  lEROPOMPHO  LY  X  463 

CHIEROPOMPHOLYX. 

This  disease,  often  better  known  as  Pompholix  or  Dysidrosis, 
consists  of  sago-like  vesicles  rising  from  the  prickly  layer  of  the  skin 
affecting  symmetrically  the  inter-digital  parts  of  the  hands  and  feet. 
Their  advent  is  accompanied  by  intense  itching  and  burning,  but  they 
are  not  surrounded  by  any  inflammatory  zone.  These  vesicles  may 
run  together,  forming  bulk'e  containing  clear  fluid  which  may  dry  up 
and  scar  over.  The  whole  of  the  extremities  may  be  attacked,  clusters 
forming  early  about  the  sweat  glands  and  often  pressing  upon  them. 

The  attack  lasts  about  tw^o  weeks,  but  recurrence  is  common. 

To  scratch  them  may  cause  a  troublesome  eczema. 

The  cause  is  unknown.  Some  afiirm  that  it  is  a  vasomotor 
neurosis. 

TREATMENT. 

Treat  as  for  pruritis.  Avoid  all  that  promotes  excessive  sweating. 
Prick  the  vesicles  with  a  sterile  needle  and  bathe  them  frequently  in 
sublimate    lotion.      Cotton    wool    placed    between    the    toes    aids    the 

process. 

CHLOASMA. 

This  disorder  is  an  anomaly  of  pigmentation  of  the  exposed  parts. 
The  varieties  are  classified  according  to  the  known  causative  agents, 
such  as  :  — 

Chloasma   solare,   due   to  exposure   to   the   sun,    glacial    glare   and 
other  powerful  light, 
caloricum,   following  exposure  to   heat, 
traumaticum,    following   mechanical    irritation, 
due  to  irritating  drugs, 
malaricum,  in  cases  of  chronic  malaria, 
symptomaticum,  or  better  perhaps,  C.  uterinum,  found 
in  some  cases  of  pregnancy  and  diseases  of  the  female 
genital  organs. 
Hyperpigmentation   is    seen    in    many    diseases,    as    Tuberculosis, 
Syphilis,   Leprosy,  Diabetes,  Addison's  disease,  Kala-azar,  &c. 

COOLIE  ITCH. 

A  general  contagious  itching  eruption  of  unknown  causation  affect- 
ing the  extremities,  and  rarely  the  whole  body.  The  eruption 
resembles  scabies,  but  no  Acarus  scabiei  can  be  found. 

Sulphur  and  naphthol  ointments,  3  to  10  per  cent.,  should  be  used. 

COPRA  ITCH. 

A  troublesome  dermatitis  caused  by  an  Acarus-like  parasite  of  the 
Tyroglyphus,  which  swarms  in  copra  and  affects  people  handling  it. 
The  mite  does  not  burrow  into  the  skin.     The  disease  lasts  as  long  as 


464  DISEASES   OF   THE  SKIN 

the    subject    handles   copra.     Beta-naphthol   ointment,    5  per   cent,    to 
10  per  cent.,  can  be  used,  but  the  mite  leaves  the  skin  at  night  time  in 

any  case. 

CORDYLOBIASIS. 

The  invasion  of  the  skin  by  the  larvae  of  Cordylobia  anthropophaga. 

The  larval  excrement  forms  the  black  centre  in  the  small  elevated  area, 

CRAW-CRAW    (Nodular   Dermatitis). 

African  natives  use  the  above  term  for  most  skin  eruptions,  but  it 
is  most  likely  more  truly  applicable  to  a  condition  of  hard  papules  or 
papulo-pustules,  of  various  shapes  and  sizes,  often  exfoliated  at  the  top, 
irregularlv  distributed  over  the  extremities,  more  rarely  over  the  whole 
body,  and  occurring  chiefly  in  West  Africa.  Pyogenic  infection  is 
common. 

The  lymphatic  glands  draining  the  area  are  afifected.  Some  cases 
clear  up  spontaneously,  others  may  last  for  months  and  even  years. 

The  cause  is  unknown,  but  some  blame  a  microfilaria. 

TREATMENT. 

The  treatment  found  most  useful  is  to  open  the  papules  or  pustules,, 
remove  the  crusts,  scrape  the  ulcers,  scrub  them  with  sublimate 
solution,  dust  with  boric  powder,  and  cover  them  with  vaseline  on  lint, 
leaving  the  dressing  on  for  one  week  (Emily). 

Internal  medication  is  not  eflficacious. 

Some  use  a  2  per  cent,  salicylate  lotion,  followed  by  5  per  cent,  to 
10  per  cent,  naphthol  ointment. 

CREEPING  DISEASE  OR   ERUPTION. 

An  eruption  characterized  by  a  raised  red  line  up  to  one  inch  in 
widtli,  which  lengthens  at  the  rate  of  from  one  to  several  inches  daily 
in  a  sinuous  or  straight  line,  the  commencement  of  the  line  fading  as 
the  other  end  progresses.     There  is  much  pruritus. 

Larvae  of  the  genus  Gastrophilus  and  other  genera  have  been  found 
in  several  cases,  but  in  others  parasites  were  absent. 

The  disease  ma\'  last  for  months  or  }-ears. 

Treatment  is  difficult.  Some  give  subcutaneous  injections  of 
cocaine  and  chloi'oform.     Treat  as  for  pruritus. 

DERMATITIS  BULLOSA  PLANTARIS. 

A  recurring  condition  of  blebs  on  the  soles  of  the  feet,  first  described 
by  Cantlie.  The  blebs  form  in  the  wet  season  and  disappear  in  the 
dry,  the  condition  recurring  annually  for  ten  to  twenty  years,  and 
sometimes  after  the  patient  has  returned  to  Europe. 

The  blebs  burst,  and  scaly  flakes  of  skin  form  over  the  soles  of  the 
feet  and  between  the  toes.     There  is  intense  itching. 


DERMATITIS    CUPOLIFORMIS  465 

Treatment  is  difficult.  A  warm  carbolic  2  per  cent,  foot  bath  daily- 
can  be  tried,  followed  by  some  antiseptic  dusting  powder,  such  as  zinc 
oxide. 

Iodide  is  useful.  Ointments  are  not  to  be  used  as  the  parts  should 
be  kept  dry.     Moist  applications  should  be  avoided. 

DERMATITIS   CUPOLIFORMIS. 

A  nodulo-ulcerative  condition,  chiefly  atTecting  Europeans,  seen  in 
Ceylon  and  described  by  Castellani. 

First  one  notices  several  small  dusky  spots  about  the  lower  ex- 
tremities, some  disappear,  while  others  become  hard,  raised,  infiltrated 
sometimes  without  vesication  or  pustulation.  Each  may  vary  in  size 
from  a  cherry  to  a  pea,  the  centre  becoming  cupoliform.  Later  there 
is  ulcer  formation.  These  ulcers  are  painful,  slow  healing,  requiring 
about  twelve  months,  and  leaving  hyperpigmented  spots. 

A  Gram-positive  streptococcus,  S.  tropicalis,  is  said  io  be  the 
causative  agent. 

The  condition  is  very  resistant  to  treatment.  Autogenous  vaccines 
give  the  best  results.  Antiseptic  lotions,  followed  bv  Peruvian 
balsam,  can  be  tried. 

DERMATITIS  EXFOLIATIVA  (Pityriasis  rubra). 

This  is  an  inflammatory  condition  of  the  skin,  characterized  by 
universal  redness  without  infiltration  or  thickening,  but  accompanied 
by  profuse  desquamation,  the  flakes  varying  in  size  with  the  various 
parts  of  the  body.  It  may  follow  other  skin  diseases  or  be  independent. 
The  onset  is  sudden  ;  the  eruption  rapidly  becomes  general ;  the  tint, 
bright  scarlet  in  Europe,  is  white  or  brownish  in  tropical  climes;  the 
scales  are  arranged  like  slates  on  a  roof  and  are  never  clumped  into 
crusts.     Itching  is  usually  absent,  but  occasionally  may  be  profound. 

The  disease  is  rare.     The  causation  is  obscure. 

TREATMENT. 

Antimony  is  useful  in  acute  cases,  arsenic  in  chronic  ones. 

Chills  are  liable  to  become  dangerous. 

The  following  local  applications  will  be  found  useful  :  — 

Diluted  liquor  picis  carbonis. 

Very  weak  creoline. 

Carbolized  oil,  i  in  20. 

^     Glycerine  of  sub-acetate  of  lead      ...     i  oz. 
Pure  glycerine  ...  ...         ...      i    ,, 

Water i  pint 

Apply  to  the  whole  body  on  lint. 


466  DISEASES   OF  THE  SKIN 

DERMATITIS   MACROGYRATA. 

A  condition  of  large  persistent,   scaly,   crusty   gyrations  upon  the 
palms  met  with  in  Southern  India.     The  cause  is  unknown. 
Treatment  has  not  been  found  efficacious. 

DERMATITIS    NODOSA    RUBRA. 

A  general  eruption  of  large,  hard,  angry  red  papules  without 
umbilication  or  scales.     The  pruritus  is  almost  unbearable. 

The  disease  may  last  six  to  twelve  months  and  then  clear  up 
spontaneously. 

It  resembles  the  papular  stage  of  small-pox,  but  there  is  no  fever 
and  no  scarring.     The  causation  is  unknown. 

Salicylic-alcoholic  lotions,  2  per  cent.,  are  useful.  Internal 
medication   has   not   improved  the  condition. 

DERMATITIS   RIMOSA  OF   THE   TOES. 

A  condition  of  severe  pruritus,  followed  by  the  formation  of  fissures 
between  the  toes.     The  condition  is  dif^cult  to  cure. 

Warm  carbolic  foot  baths  and  zinc  oxide  powder  will  assist  much. 

DERMATITIS  SOLARIS. 

This  is  an  advanced  condition  of  erythema  solare. 
Avoid  exposure  to  the  sun. 

DERMATITIS    VENENATA. 

An  inflammatory  condition  of  the  skin  caused  by  contact  with 
certain  poisonous  plants  and  timbers. 

The  following  classification  has  been  suggested  by  Castellani  :- — 

(1)  The  Rhus  Group. 

Plants  in  wliicii  the  poisonous  principle  is  contained  in  a  clear 
watery  fluid,  e.g.,  poisonous  ivy,  the  varnish  tree,  parsnips,  &c. 

(2)  The  Euphorbia  Group. 

Plants  in  which  the  poisonous  principle  is  contained  in  a  thick 
milky  fluid,  e.g.,  the  manchineel  tree  and  all  Euphorbias. 

(3)  The  Urtica  Group. 

Plants  in  which  the  poisonous  principle  is  contained  in  the  fluid 

of  special  hairs,  e.g.,  nettles,  primroses,  &c. 
(4<)   The  Fectona  Group. 

Dried  hard  woods,   the  dust  of  which  contains  the  poisonous 

principle,  e.g.,  teak,  satin-wood,  ebony,  rosewood,  &c.  ^ 

For  treatment  lead  lotion  and  calamine  lotion  should  be  applied. 

DERMATOPHILIASIS. 

This  is  a  local  skin  disease  due  to  invasion  by  the  pregnant  female 
jigger,  Dermatophilus  penetrans. 


DVSIDROSIS   EXFOLIATIVA  467 

Its  original  home  was  the  West  Indies  and  Tropical  America 
(30°  N.  to  30°  S.).  It  was  brought  to  Loanda,  West  Africa,  from  Rio 
de  Janeiro  about  1872.  Stanley's  expedition  probably  carried  it  across 
Africa  to  the  East  Coasr,  1895,  thence  to  India,  1899,  by  the  4th  Bombay 
Infantry. 

These  parasites  attack  man,  wild  and  domestic  animals,  especially 
the  pig.  They  live  in  dry  sandy  soil ;  when  impregnated  the  female 
burrows  into  the  skin  of  a  warm-blooded  animal,  preferably  in  man 
about  the  feet;  the  abdomen  now  swells  enormously  until  it  is  as  large 
as  a  small  pea,  the  posterior  segment  blocking  the  opening  through 
which  the  eggs  are  expelled  ;  the  eggs  become  larva?,  cocoons,  pupje 
and  imagos  in  eight  to  ten  da}-s. 

The  symptoms  are  itching,  burning  and  throbbing,  pyogenic 
infection,  suppuration  and  ulceration  when  the  parasite  is  thrown  out. 

Complications,  such  as  phagedena,  gangrene  and  tetanus,  may 
result  as  with  all  unclean  wounds. 

TREATMENT. 

Keep  the  floors  free  from  dust.  Avoid  walking  barefooted,  dust 
socks  and  boots  with  iodoform,  choose  healthy  "steward"  boys,  use 
cyllin  upon  the  floors,  extract  the  parasite  with  a  clean  needle  when 
first  felt,  and  touch  the  site  with  tincture  of  iodine. 

DYSIDROSIS   EXFOLIATIVA. 

A  continuous  and  excessive  perspiration  of  certain  parts,   usually 
the  palms,  resulting  in  flaky  exfoliation  of  the  epidermis. 
A  trip  to  the  hills  will  usually  clear  up  the  condition. 

ECZEMA. 
DEFINITION. 

A  catarrhal  inflammation  of  the  skin,  originating  without  visible 
external  irritation,  characterized  by  serous  exudation  in  some  stages 
of  its  evolution  (Morris). 

SYMPTOMATOLOGY. 

It  seems  to  rise  spontaneously;  has  no  regional  limitations;  has  no 
definite  course,  and  too  often  defies  all  attempts  of  the  medical 
attendant  to  clear  it  up.  There  are  erythematous  lesions,  papules,, 
vesicles  which  when  ruptured  discharge  a  secretion  that  stiffens  linen, 
later  crustation  and  desquamation  may  predominate  in  turn.  Itching 
is  often  unbearable,  but  constitutional  disturbances  are  slight. 
Scratching,  which  it  is  exceedingly  difficult  to  resist,  may  lead  to 
pyogenic  infection  and  ulceration  with  enlargement  of  the  proximal 
lymphatic  glands. 


468  DISEASES   OF   THE  SKIN 

VARIETIES. 

Seborrhoeic  eczema,  based  upon  excessive  seborrhoeic  secretion 
(Hydrosis  oleosa).  The  Staphylococcus  epidermidis  albus  may  con- 
tribute to  the  cause. 

Sweat  eczema,  based  upon  excessive  secretion  of  sweat,  acting  as 
a  softening-  and  irritating  agent  to  the  skin. 

Follicular  eczema,  based  upon  an  inflammatory  condition  of  the 
hair  follicles,  possibly  of  microbic  origin. 

Nervous  eczema,  based  upon  reflex  irritation  of  the  skin  after 
nervous  shock,  mental  strain,  and  after  dentition. 

Most  eczemas  are  of  microbic  origin,  the  organisms  proliferating 
when  there  is  some  slight  abnormality  of  skin  function,  the  process 
then  extending  by  auto-inoculation  and   reflex  irritation. 

TREATMENT. 

The  less  drugging  the  better.     Avoid  arsenical  preparations. 

In  selected  cases  antimony  (vinum),  calomel  and  opium  for  nervous 
cases  are  useful. 

When  and  where  possible  send  to  a  cool  climate. 

Locally,  remove  crusts  and  scales  with  weak  solution  of  sodium 
bicarbonate;  relieve  itching  by  warm  solutions  of  boric  acid,  followed 
by  dry  boric  powder  \\{{\\  starch ;  protect  from  the  air  by  creams  and 
salves;  use  sulphur  for  the  seborrhoeic  varieties. 

ERYSIPELAS. 

This  form  of  streptococcal  cellulitis  and  dermatitis  is  nut  un- 
common. Licj.  ferri  perchlor.  fort,  and  Liq.  arsenicalis  internally  with 
ichthyol  ointment  externally  will  be  found  efficacious. 

In  resistant  cases  diphtheritic  anti-serum  has  proved  useful. 

ERYTHEMA  SOLARE. 

Europeans,  during  the  early  years  of  tropical  open-air  life,  are 
subject  to  tiiis  erythema  caused  by  the  sun's  violet  rays.  There  is 
some  descjuamation  and  pigmentation. 

Vaseline  is  useful,  but  sensitive  skins  should  be  protected  by  sun 
imibrellas  as  a  troublesome  dermatitis  may  ensue. 

ERYTHASMA. 

This  consists  of  brownish  red  scaly  patches  in  the  genito-crural 
region  or  elsewhere  caused  by  the  Microsporon  minutissimum. 

Wash  with  soap  and  water,  apply  linamentum  terebene ;  later, 
resorcin  and  salicylic  ointments. 

GANGOSA. 

See  article  on  Gangosa,  section  on  "  Diseases  of  Uncertain 
.Etiology." 


GRANULOMA   INGUINALE  469 

GRANULOMA   INGUINALE. 

Serpiginous  ulceration  of  the  genitalia  is  widely  spread  in  its  dis- 
tribution. It  is  a  chronic  vascular  granuloma,  probably  of  protozoal 
origin,  attacking  the  external  genitals  of  both  sexes,  and  spreading  to 
tile  inguinal  region  and  perina?um.  It  does  not  tend  to  suppurate 
or  caseate. 

The  condition  is  painful,  disfiguring,  contagious,  and  exceedingly 
difficult  to  cure.  It  may  by  becoming  oedematous  simulate  elephan- 
tiasis in  its  early  stages.  It  occurs  between  puberty  and  45  years  of 
age.  The  general  health  is  but  slightly  affected.  Scarring  may  lead 
to  ultimate  healing. 

TREATMENT. 

Radiotherapy  has  been  found  effective. 
Excision  and  scraping  in  later  stages  are  helpful. 
Neosalvarsan  has  its  advocates.     Tartar  emetic  may  be  useful. 
Iodides  in  large  doses  can  be  tried. 

GRAIN  ITCH. 

An  itching  eruption  of  weals  and  vesicles,  some  of- which  become 
pustules,  affecting  the  neck,  chest,  abdomen  and  back,  found  in  work- 
men who  handle  new  straw  mattresses  which  are  infected  with  the 
Pediculoides  ventricosus.  The  hands,  strangely  enough,  nearly 
always  escape. 

TREATMENT. 

1^      Beta-naphthol  30  grains 

Sulphur  prsecip.  ...  ...         ...     40      ,, 

Adipis  benzoat.  ...         ...         ...     i  ounce 

HAIR  AFFECTIONS. 

These  are  caused  as  a  result  of  :  — 

(A)  Inflammation  wuth  subsequent  atrophy  of  the  hair  follicle, 
leading  to  increase  or  decrease  of  the  hair  pigment,  atrophy, 
and  total  destruction  of  the  hair. 

(B)  Concretions  formed  on  the  hair  shaft. 

(C)  Parasitic  diseases  such  as  ringworm.  These  are  dealt  with  in 
another  place. 

(1)  Alopecia. 

This  condition  is  usuallv  due  to  one  of  the  following  causes  :  — 
A  senile  change  which  is  sometimes  congenital,  at  other  times 
syphilitic  (second  stage). 

A     febrile    or    any    other    general     disease    interfering    with 
nutrition. 
30 


lO 

drachms 

2 

»> 

6 

ounces 

25 

drachms 

10 

ounces 

470  DISEASES   OF  THE  SKIN 

Any  pressure  of  the   temporal   arteries  or  veins   of   the   scalp 

by  hard  unventilated  hats. 

Profuse  perspiration  with  bacterial  invasion  and  decomposition 

of  the  hair. 

Chronic  seborrhcea,  and  a 

Neurosis  when  it  is  local  and  follows  the  track  of  some  nerve. 

TREATMENT. 

To   remove  the   cause,    e.g.,    clear   up   the   syphilis,    treat   the 

febrile  or  general  disorder,  remove  the  pressure  on  the  vessels, 

correct  the  nutrition,  &c. 

Stimulate    the    blood    supply    of    the    scalp    locally    with   mild 

irritant. 

Nourish  the  follicles  externally  by  ointments. 

External     Irritants. — There    are     endless    varieties.     A     good 

one  is  : — 

R     Borate  of  soda 

Salicylic  acid 

Tinct.  of  cantharides  ... 

Bay  rum... 

Rose  water 

Boiling  water  to  ih  pints. 

Nourishing  Ointments. — A  good  one  is  :  — 

^     Acid  salicyl ...       5  grains 

Sulph.  praecipitat.        ...         ...         ...  ...  15       ,, 

Beta-naphthol    ...         ...  ...  ...  ...  10       ,, 

Vaseline  to  one  ounce. 

(2)  Canities. 

A  senile  change  usually  causes  greyness,  but  the  condition 
of  grey  hairs  may  be  congenital,  the  result  of  disease,  nervous 
shock,  or  long-continued  nervous  exhaustion. 
In  elderly  persons,  treatment  other  than  dyeing  is  useless, 
while  in  younger  persons  cure  is  very  doubtful. 
Black  hair  may  result  from  pilocarpine  injections  given  for 
any  reason. 

Aniline  dyes  will  cause  a  deep  red  brown  colour  of  the  hair 
in  some  dye  workers. 

Green  hair  is  caused  by  copper  amongst  copper  smelters. 
Blue  hair  is  caused  amongst  workers  in  cobalt  mines. 
For  the  treatment  of  grey  hair  in  young  persons  the  follow- 
ing can  be  tried  :    Tinct.  of  jaborandi,   internally,    15  minims 
t.d.s.,  or  pilocarpine  hydrochlorate,  hypodermically,  gr.  ^^  to  . 

(3)  Dermatitis  Papillaris  Capillitii. 

An    inflammatory    process,    commencing   on    the   back    of    the 
neck  and  spreading  upwards.     The  papules  form   large  rasp- 


HAIR   AFFECTIONS  471 

berry-like    vegelations,    which    bleed   readily   and    give   off   an 
offensive  odour  and  discharge.     These  vegetations  are  charac- 
teristic of  the  disease.     Abscesses  may  form. 
Later    the    vegetations    shrink    and    heal     spontaneously    by 
scarring. 

(4)  Folliculitis  Decalvans. 

A  chronic  folliculitis  of  the  scalp  leading  to  cicatrization  and 
baldness.     Use  anti-parasitic  ointments  and  stimulating  lotions. 

(5)  Leptothrix. 

Concretions  upon  the  hairs  of  the  axillary  and  scrotal  regions. 

The  hairs  are  very  brittle  and  break  readily. 

The    origin    is    bacterial.     Use    cleanliness    and    anti-bacterial 

ointments. 

(6)  Monilethrix. 

Beaded  hair  aft'ecting  almost  all  the  hairy  parts  of  the  body. 
The  pigment  is  collected  in  the  nodes,  the  hairs  breaking  off 
at  the  narrow  parts.     Young  people  are  generally  affected. 
It  is  probably  due  to  atrophic  changes  at  periodic  intervals. 
A  modification  of  this  condition  is  known  as  "bayonet  hair." 

(7)  Overgrowth  =  hirsuties. 

This  condition  is  usually  associated  with  some  anomaly  of 
dentition,  insanity,  disorder  of  menstruation,  barrenness, 
severe  illness,  local  irritation  and  heredity. 

Treatment  is  of  no  avail  permanently  apart  from  electrolysis, 
by  which  means  isolated  large  hairs  are  removed  with  the 
hair  follicles.  Local  remedies  simply  scour  off  the  hairs  like 
pumice-stone  applications. 

(8)  Piedra. 

Small,  black,  gritty  concretions  that  rattle  on  combing  the  hair. 
They  are  closely  packed  pigmented  spore-like  bodies,  due  in 
all  probability  to  the  Trichosporon  giganteum.  It  is  common 
in  Colombian  women. 

(9)  Pseudopelade. 

Irregularly  shaped  patches  of  baldness  which  coalesce,  cicatrize 
and  destroy  the  follicles.  Adults  with  coarse,  dark,  wiry  hair 
are  usually  the  victims.     Treatment  is  of  little  avail. 

(10)  Tinea  Nodosa. 

A   nodular  concretion   caused   by   fungus  spores  affecting  the 

beard  and  moustache. 

Shave  and  apply   antiparasitic   remedies. 


472  DISEASES   OE   THE  SKIN 

(11)  Trichomycosis  Capillitii. 

Similar  to  Leptothrix,  but  due  to  a  different  organism. 

(12)  Trichorrhexis  Nodosa. 

Small  bead-like  whitish  swellings  resembling  "nits"  on  the 
hair  shaft  causing  the  cortex  to  split,  while  the  medulla 
remains  unbroken.  The  condition  is  probably  due  to  a  diplo- 
coccus. 

TREATMENT. 

Epilation  of  diseased  hairs,  or 

Frequent  shaving  and  anti-parasitic  remedies. 

HERPES. 

A  cluster  of  transparent  vesicles  the  size  of  a  pin's  head  to  a  pea, 
numbering  from  two  to  twenty,  seated  on  an  erythematous  patch  and 
surrounded  by  an  inflammatory  zone. 

There  are  two  types,  Herpes  febrilis  and  Herpes  zoster  (Shingles). 

The  former  is  designated  Herpes  labialis,  facialis  or  progenitalis, 
according  to  its  position.  It  is  symptomatic  of  febrile  disorders,  but 
tvphoid  fever  is  a  noted  exception. 

Herpes  zoster  is  nervous  in  origin,  and  follows  the  distribution  of 
one  or  more  of  the  posterior  spinal  roots  on  the  skin.  These  nerves 
correspond  whh  those  nerves  that  become  tender  in  visceral  dis- 
turbances. 

TREATMENT. 

Menthol  or  collodion  externally  and  morphia  internally  may  be 
required ;  otherwise  for  all  herpes  treat  the  general  disorder  and  apply 
anti-pruritic  lotions  and  ointments  locally. 

HYPERIDROSIS. 

General  or  local  excessive  perspiration. 

It  is  often  associated  with  prickly  heat. 

Do  not  try  to  check  the  excessive  sweating,  a  physiological  action, 
by  belladonna,  but  add  cyllin  to  the  daily  bath,  and  dust  the  body  with 
antiseptic  powder.     Change  the  clothing  frequentlv. 

ICHTHYOSIS  (c^ed<;  =a  fish). 
A    dry,    rough,    scaly    and    sometimes    warty    skin    of    uncertain 
causation,  usually  congenital,  but  rarely  acquired. 

VARIETIES. 

(1)   Ichthyosis  FoUicuIaris. 

Horny  skin,  patches  of  baldness,  hair  replaced  in  certain  areas 
by  pin-head  papules  which  are  surmounted  by  hornv  spines. 
It  is  non-inflammatory. 


IMPETIGO  473 

(2)  Ichthyosis  Hystrix  {vaTpi^  =-  a  porcupine). 

A  rare  condilion.  It  consists  of  loni^iludinal  patches  on  the 
limbs  and  transverse  patches  on  the  trunk,  corresponding  with 
the  distribution  of  the  cutaneous  nerves  and  associated  with  a 
general  xerodermia.  Such  ridges  may  rise  half  an  inch  above 
the  surrounding  skin. 

TREATMENT. 

Cure     is     exceptional.      Improvement     has     followed     thyroid 
extract,    soft    soap    and    warm    baths  with    vigorous    friction, 
lanoline  or  salicylic  acid  inunctions  in  the  last  variety. 
Some  patches  may  require  excision  or  scraping. 

(3)  Ichthyosis  Simplex. 

Extreme  scaliness,   may  be  horny  like  the  hide  of  a  crocodile 
and  of  a  similar  colour.    The  nails  break  easily.    There  is  slight 
improvement   in   the   summer.      There  is   much   itching,    great 
sensitiveness  to  cold,  and  a  tendency  to  "  chap  "  deeply. 
(4^)   Keratosis  Pilaris   (Xerodermia). 

This  is  the  commonest  form.     The  skin  feels  to  be  hard  like  a 

nutmeg  grater,  hence  the  name.     There  are  dry  skin,  imperfect 

development  of  hair,  and  changes  in  the  sebaceous  and  sweat 

glands. 

Give  inunctions  of  myelocene ;  also  castor  oil,  followed  by  mag. 

sulph.  and  plain  water  enema. 

IMPETIGO. 

A  pustular  eruption  caused  by  scratching,  followed  by  inoculation 
of  streptococci  and  staphylococci.  The  proximate  lymphatic  glands 
enlarge  and  may  suppurate.     The  condition  is  contagious. 

Remove  scabs  by  carbolized  oil  or  carbolic  acid  lotion,  i  in  lOO. 

Apply  mercurial  and  other  antiparasitic  ointments. 

Vaccines  may  be  required. 

Mag.  sulph.  and  tonics  are  useful. 

INTERTRIGO  SACCHAROMYCETICA. 

A  rare  inflammatory  condition  attacking  the  scrotocrural  and 
axillary  regions  caused  by  a  Saccharomyces. 

Antiparasitic  lotions  and  inunctions  will  clear  it  up. 

JUXTA-ARTICULAR  NODES. 

Multiple  subarticular  movable  nodules  about  the  elbow  and  knee- 
joints  usually,  probably  caused  by  the  fungus  Nocardia  carougeaui. 

The  writer  has  seen  many  cases  in  the  Choco,  Colombian  Republic, 
in  some  of  which  twenty-four  nodules  could  be  counted  about  the  joints 
mentioned,  many  of  them  being  the  size  of  a  walnut. 

Excision  is  advisable  when  thev  interfere  with  articular  movements. 


474  DISEASES   OE  THE  SKIN 

KAPOSI'S    DISEASE    (Xerodermia   pigmentosum). 

A  rare  formation  of  numerous  tumours,  running  a  malignant  course, 
and  ultimately  causing  death  by  exhaustion. 

The  condition  commences  as  "freckles,"  which  develops  into  a 
warty  condition,  and  later  into  ulcerating  fungoid  masses,  destroying 
all  approximate  tissue.  The  tumours  are  epitheliomatous  in  structure, 
but  there  are  no  secondaries. 

The  disease  commences  early  in  life  as  a  rule,  and  requires  years  for 
its  development. 

Avoid  the  sun's  rays.  Excise  patches  and  tumours.  Try  X-ra}S 
and  electrotherapy. 

KERATOMA  PLANTARE  SULCATUM. 

A  thickening  of  the  epidermis  of  the  heels  and  soles  with  deep 
furrows,  at  the  base  of  which  a  whitish  fungus  can  be  found. 

Walking  is  often  painful. 

The  only  known  efificacious  remedies  are  preparations  of  salicylic 
ointment,  plaster  and  collodion. 

LEUCODERMA. 

A  patchy,  non-pigmented,  white  or  pinkish  condition  of  the  skin ; 
chronic  and  incurable;  found  in  coloured  races.  The  patches  are 
irregularly  shaped  and  distributed;  local  or  universal,  but  without  any 
modification  of  the  skin  functions.  The  condition  is  chieflv  of  nervous 
origin,  but  occasionally  fungi,  burns,  or  injuries  mark  its  onset.  The 
hair  over  the  patches  is  whitish. 

Exposure  to  the  sun  causes  a  burning  sensation  over  such  areas, 
and  patients  often  complain  of  weakness  or  giddiness,  making  them 
unfit  for  any  tropical  outdoor  work. 

Some  have  found  arsenical  preparations  useful. 

The  patches  ma\'  be  darkened  by  silver  nitrate,  potassium  perman- 
ganate, or  tattooing. 

LICHEN  CONVEX. 

A  chronic,  pruriginous,  papular,  non-inflammatory  eruption, 
pinkish  in  natives  and  reddish  in  Europeans,  leaving  no  excess  of 
pigmentation  on  healing.  The  disease  lasts  three  to  nine  months  and 
may  recur. 

There  is  no  scaling,  and  the  convex  papules  never  show  "plugs." 
There  may   be   spontaneous   healing.     The   general    health    is    not 
affected. 

Internal  remedies  have  no  effect. 

Externally  use  a  salicylic-alcoholic  lotion,  2  per  cent.,  followed  by 
naphthol  ointment,  5  per  cent. 


LICHEN  PLANUS 


475 


LICHEN  PLANUS. 

The  term  "lichen"  does  not  mean  much  more  than  '"papular," 
thus  lichen  simplex  is  really  a  phase  of  eczema,  and  lichen  tropicus 
the  same  as  prickly  heat,  &c.  The  word  should  be  restricted  to 
eruptions  that  are  papular  throughout  and  of  a  persistent  typical  form. 

Lichen  planus  consists  of  a  violet  or  reddish  eruption  of  small, 
irregularly  shaped  papules,  flat  on  the  top  and  sometimes  umbilicated, 
carrying  a  small  scale  "in  the  centre.  It  is  probably  of  an  angio- 
neurotic origin.  The  papules  may  group  themselves  in  lines,  curves, 
or  rings.  Vesicles  seldom,  and  pustules  never,  appear  in  adults.  The 
mucous  membrane  may  be  affected,  but  the  accompanying  skin  con- 
dition will  assist  the  diagnosis.  In  acute  cases  there  is  much  depression 
and  irritability. 

Arsenic  is  useful  given  in  increasing  doses  over  long  periods,  but 
improvement  is  not  to  be  expected  until  after  the  sixth  week  of  treat- 
ment.    Intestinal  antiseptics  are  useful.     Morris  uses  the  following:  — 


R 


Liq.  hydrarg.  perchlor. 
Potass,  iodid. 
Decoct,  sarsae.  co.    ... 


I  ounce 
40  grains 
8  ounces 


Take  one  ounce  thrice  daily. 


y  '— 

R 

Corros.  sublimate 

roo  gramme, 

Carbolic  acid 

20-00         ,, 

Simple  ointment        

500-00         „ 

Apply  twice  daily. 

LICHEN  TROPICUS. 


See   Prickly   Heat. 


LUPUS  ERYTHEMATOSUS. 

An  inflammatory  condition  with  cellular  infiltration,  terminating  in 
atrophy  of  the  affected  skin.  It  is  often  symmetrical,  and  commences 
by  primary  spots  having  a  red  or  pinkish  elevated  thickened  edge  and 
a  depressed  centre.     The  redness  fades  on  pressure. 

The  face  is  most  commonly  attacked  in  the  "  butterfly  area." 

The  disease  lasts  from  ten  to  twenty  years,  when  it  clears  up. 

Patients  are  most  frequently  women  from  25  to  45  years  of  age. 

Anv  slight  wound  causing  a  disturbance  in  the  local  circulation, 
such  as  a  mosquito  bite,  will  mark  the  site  and  time  for  its  onset. 

To  differentiate  it  from  Lupus  vulgaris  :  — 


Lupus  erythematosus. 

Begins  as  small  red  spots. 
No  ulcrration. 
Always  superficial 
Develops  after  puberty. 


Lupus  vulgaris. 

Begins  as  soft  apple-jelly  nodules. 
Ulceration  frequent. 
Cartilage  may  be  affected. 
Develops  usually  before  puberty. 


476  DISEASES   OF   THE  SKIN 

TREATMENT. 

Avoid  stimulanls,  irritants  and  sea  air. 

Examine  for  auto-inoculation,  and  deal  ^vilh  it  when  found. 
If  intestine  is  affected  give  salol,  ichthyol,  &c. 
Tincture  of  iodine  externally  is  often  good. 

For  chronic  cases,  carbon-dioxide  snow,  ionization  with  zinc  or 
copper,  high-frequency  current  and  Finsen  light. 

MONGOLIAN  SPOTS. 

Mulberry  coloured,  smooth,  non-elevated  spots,  occurring  usually 
about  the  sacral  region,  the  colour  not  disappearing  on  pressure. 

It  is  of  unknown  origin,  and  is  found  chiefly  amongst  the  Chinese, 
Koreans,  Japanese,  Malays,  Italians  and  Europeans.  The  spots  may 
be  single  or  multiple,  one  to  six  or  more.  They  appear  at  birth,  and 
spontaneously  disappear  about  the  third  or  fourth  year. 

No  treatment  is  necessar}^ 

MOSSY  FOOT. 

A  dense,  warty,  vascular,  painful  condition  of  the  foot,  occurring 
in  masses,  seen  chiefly  amongst  the  Amazonians.  It  is  of  uncertain 
origin  and  of  chronic  course.  Cranston  Low  suggests  that  it  is  Tuber- 
culosis cutis  verrucosa.  The  masses  may  be  half  to  three-quarters  of 
an   inch   high. 

THE  MUCOUS  MEMBRANE. 

Pathological  skin  conditions  affecting  the  mucous  membrane 
secondarily  are  dealt  ^^•ith  elsewhere.  Disorders  arising  more  or  less 
primarily  are  dealt  with  here. 

Black  Tongue  (Hairy  tongue). 

A  dark  brown  or  blackish  hyperkeratosis,  usually  in  front  o'f  the 
rircumvallate  papillae,  commencing  in  the  mid-line,  found  usually  in 
adult  males,  persisting  for  weeks  and  perhaps  years,  and  then  spon- 
taneously disappearing. 

Treatment,   apart  from  mouth  washes,   is  unnecessary. 

Cheilitis  Exfoliativa. 

A  persistent  exfoliation,  recurring,  of  the  vermilion  of  the  lips, 
accompanied  by  numbness  or  burning  pain,  probably  caused  by  the 
liabit  of  gnawing  and  picking  the  lips  in  neurotic  individuals.  Radium 
may  clear  up  the  condition. 

Cheilitis  Glandularis. 

A  chronic  inflammation  of  the  lower  lip  with  enlargement  of  the 
mucous  glands,  dilatation  of  the  follicular  openings,  the  formation  of 
fistulous  tracts  which  discharge  a  viscid  secretion,  sometimes  fixing 
the  lips  together  during  the  night. 


THE  MUCOUS   MEMBRANE  477 

There  is  often  a  previous  catarrh  of  tlie  mouth  and  pharynx. 
Silver  nitrate  caustics,   potassium  chlorate   gargle,    and   potassium 
iodide  internally  are  most  successful. 

Fordyce's  Disease. 

Small  whitish  bodies  affecting  the  lips  and  mouth,  accompanied 
by  a  feeling  of  stift'ness.  The  condition  tends  to  become  permanent. 
Treatment  is  discouraging.     Caustics  and  scraping  may  be  tried. 

Glossitis  Areata  Exfoliativa. 

Small,  greyish,  well-defined,  slightly  elevated  spots  near  the  tip  of 
the  tongue,  desquamation  in  the  centre  and  spreading  at  the  periphery, 
sometimes  forming  circles  or  festoons  suggesting  the  "  langue 
geographique." 

It  usually  occurs  in  children,  and  is  frequently  confined  to  families. 
Its  origin  is  unknown. 

Treatment  is  disappointing. 

Grooved  Tongue. 

Single  or  multiple  grooves  on  the  dorsum  of  the  tongue  in  which 
food  particles  accumulate  requiring  the  constant  use  of  a  mild  anti- 
septic mouthwash. 

The  condition  is  often  congenital  and  confined  to  families. 

Treatment  is  useless. 

Ichthyosis  Glossse. 

A  condition  of  leucokeratosis  of  the  tongue  resembling  tylosis 
(keratosis  of  the  palms  and  soles). 

Kraurosis  Vulvae. 

Atrophy  of  the  vulv^,  with  stenosis  of  the  orifice  occurring:  — 
(i)  After  the  menopause, 

(2)  As  a  sequel  of  oophorectomy, 

(3)  In  sterile  young  women  (rare). 
Treatment  is  surgical  when  necessary. 

Leucoplakia  of  the  Tongue. 

It  may  be  Syphilitic,  Parasyphilitic,  or  Idiopathic. 
Predisposing  factors  are  :  clay-pipes,  tobacco-smoke,  bad  dentures, 
ragged  tooth  stumps. 

The  ulcerating  fissures  may  become  the  seat  of  epithelioma. 
Always  exclude  syphilis.     Caustics  make  the  condition  worse. 
Hot  fluids  and  spices  are  to  be  avoided. 
Radium  can  be  tried.     Excision  may  be  necessary. 
Leucoplakia  may  also  affect  the  penis,  vulva  and  vagina. 
Use  X-rays,  radium  and  excision  where  necessary. 


4/8 


DISEASES   OF  THE  SKIN 


Perleche. 

A  chronic  stomatitis  usually  afifecting  the  commissures;  commonly 
seen  in  children.  The  fissure  divides  the  two  patches  into  equal  parts 
at  the  commissure.  The  child  frequently  licks  its  lips,  hence  the  term 
"pour  lecher,"  perleche. 

The  condition  is  probably  caused  by  a  streptococcus  and  is  infec- 
tious.    It  lasts  two  to  four  weeks  and  then  spontaneously  clears  up. 

Relapse  is  common. 

Cauterize  with  copper  sulphate  and  appl_y  zinc  oxide  ointment. 

MYCETOMA   (Madura  Foot). 

Madura  was  a  district  in  India  where  the  disease  was  very 
prevalent. 

It  is  an  invasion  of  the  hand,  but  more  usually  the  foot,  less  fre- 
quently other  parts  of  the  body,  by  fungi  belonging  to  the  following 
genera  :     Aspergillus,    Sterigmatocystis,    Madurella,    Indiella,    Mono- 


Madura  foot. 

sporium,  Sporotrichum  and  Nocardia.  These  produce  enlargement 
and  deformity  of  the  part,  the  condition  being  characterized  by  an  oily 
degeneration  and  tissue  fusion  with  cyst-like  cavities  and  sinuses. 

The  disease  is  chronic  and  progressive,  terminating  in  death  by 
exhaustion  if  not  removed  surgically. 

It  is  common  in  India,  Asia,  Africa,  Europe  and  America. 


MYCETOMA 


479 


ETIOLOGY  AND  PATHOLOGY  (Castellani). 

The  causal  fungi  belong  to  the  genera  numerated  above,  the 
saprophytic  life  of  which  is  quite  unknown,  except  that  of  Nocardia 
bovis,  which  lives  in  cereals.  Barefooted  natives  are  usually  affected, 
the  fungus  entering  in  at  some  wound  about  the  foot,  the  wound  heal- 


Mycetoma  of  the  foot. 

ing,  but  enclosing  the  fungus  which  grows  slowly  within,  without 
there  being  any  real  attempt  at  repair  by  the  body  except  for  some 
lymphocytic  infiltration  and  the  formation  of  some  granulation  tissue. 
Fibrous  tissue  is  formed  about  the  fungus;  endarteritis  and  peri- 
arteritis cut  off  the  blood  supply;  the  cellular  exudate  becomes  oily, 
often  foul,  discharges  at  the  surface  through  sinuses,  the  exudate 
carrying  witli  it  some  of  the  parasites.     As  Nature  thus  tries  to  throw 


48o 


DISEASES   OF   THE  SKIN 


off  the  fungus,  the  latter  forms  special  club-shaped  persistent  hyph^e 
which  asexually  propagate  the  disease  in  the  part.  Leucocytes  then 
attempt  to  get  rid  of  them  by  engulfing  the  parasites  and  succeed  in 
carrying  them  to  other  parts,  where  the  leucocyte  is  killed  by  the 
enclosed  parasite,  which  latter  again  reproduces  the  disease  where  it 
may  happen  to  be. 

When  the  fungus  is  surrounded  by  pus,  a  mass  of  debris  contain- 


'mr^ 


Mycetoma  of  the  hand. 

ing  granules — yellow,  black  or  pinkish — is  formed  and  exuded.  The 
tissue  adjoining,  muscle,  tendon,  nerve  and  bone,  degenerate  and 
break  down  into  debris;  the  body  is  drained  and  exhausted; 
emaciation  and  cachexia  set  in,  and  some  intercurrent  disease  ends  the 
scene. 

SYMPTOMATOLOGY. 

A  small  Avound,  usually  in  the  foot,  heals,  and  a  small  swelling  is 
noticed  which  is  painless.  After  one  month  or  so  the  swelling  softens, 
ruptures,    and    discharges   an    oily    blood-stained    exudate    containing 


MYCETOMA  481 

minute  coloured  granules  about  the  size  of  fish  roe.  The  whole  foot 
is  much  enlarged,  especially  in  thickness,  its  shape  is  lost,  anatomical 
points  are  obliterated,  multiple  sinuses  reach  the  surface  and  discharge 
through  their  sinuses  with  distinctive  odour.  As  the  foot  enlarges 
the  leg  atrophies  from  disuse,  thus  making  the  foot  enlargement  the 
more  noticeable.  Pain  is  usually  absent;  locomotion  is  difificult;  the 
skin  sensibility  is  normal ;  pitting  is  not  obtained,  but  the  tissue  is 
elastic. 

There  is  no  spontaneous  healing,  and  after  eight  to  twelve  years  of 
exhaustion,  diarrlura  often  carries  off  the  patient. 

VARIETIES. 

(^4)  The  Melanoid   Group. 

(i)  Carter's  black  mycetoma. 

Parasite,  ]\Iadurella  mycetoma,  Laveran,  1902. 
The  sclerotia  are  small,  hard  and  blackish. 
The  parasite  throws  off  a  blackish  debris. 

(2)  Boufifard's  black  mycetoma. 

Parasite,  Aspergillus  bouffardi,  Brumpt,  1905. 

The  grains  are  larger  and  more  elastic  than  the  above. 

Curetting  may  cure  this  condition. 

(3)  Nicolle  and  Pinoy's  black  mycetoma. 
Parasite,  Madurella  tozeuri,  Nicolle,   1908. 

(4)  Link's  black  mycetoma. 

Parasite,  Penicillium  glaucum.  Link,   1915. 

(B)  The  Ochroid  Group. 

(i)  Carter's  white  mycetoma. 

Parasite,   Nocardia  madura?,   \'incent,    1894. 

The  sclerotia  are  whitish,  mulberry-like  and  spherical. 

(2)  Actinomycotic  white  mycetoma. 

Parasite,  Nocardia  bovis  and  Israeli,  1872  and  1896. 
The  sclerotia  are  yellowish,  sulphur  colour  and  soft. 
It  destroys  bones  and  forms  metastases  throughout  the  bodv. 

(3)  Nicolle's  white  mycetoma. 

Parasite,   Sterigmatocystis   nidulans,    Eidans,    1883. 
The  sclerotia  are  large,  like  peas,  and  smooth. 
It  attacks  bone. 

(4)  Brumpt's  white  mycetoma. 
Parasite,  Indiella  mansoni,   1906. 

The  sclerotia  are  small  and  white,  occurring  as  hard  bean- 
shaped  granules. 

(5)  Reynier's  white  mycetoma. 
Parasite,  Indiella  rejieri,   1905. 

The  small  white  sclerotia  occur  in  soft  coiled  masses. 


482  DISEASES   OF   THE  SKIN 

(6)  Bouffard's  white  mycetoma. 
Parasite,  Indiella  somaliensis,    1905. 

The  sclerotia  occur  as  hard,  small,  spherical  and  polyhedral 

grains. 

It  destroys  bone. 

(7)  Musgrave  and  Clegg's  white  mycetoma. 
Parasite,  Nocardia  asteroides,   1890. 

The  sclerotia  are  first  oval,  then  vary  in  shape. 
It  invades  the  medulla  of  bone. 

(C)  The  Red  Group. 

Pelletier's  red  mycetoma. 

Parasite,  Nocardia  pelletieri,  1906. 
It  may  attack  other  parts  of  the  body. 
It  occurs  in  Africa. 

TREATMENT. 

Amputation  is  the  most  certain  cure,  well  above  the  ankle  or  wrist, 
rarely  less  than  this. 

Scraping  and  cauterizing  with  potassium  iodides  internally  may  be 
successful  in  some  cases. 

MYIASIS. 

The  invasi(jn  of  the  skin  or  other  parts  by  the  larva?  of  flies. 

(1)  Dermatobia  cyaniventris  (Oistridae). 

This  is  found  in   Tropical  America,   and  is  present  in  cattle, 
pigs,  dogs,  monkeys,  birds,  and  rarely  in  man. 
There  is  local  pain,   itching,   swelling,   oedema  with  a  central 
sinus,  in  which  the  larva  may  be  seen  from  time  to  time. 
The  larva  may  attack  any  part. 

(2)  Cordylobia  anthropophaga  (Muscid^e). 

It  is  common  in  Africa,  where  it  is  known  as  Tambu  fly  disease. 

In  Europeans  the  thighs  and  buttocks  are  usually  affected,  the 

source  of  infection  probably  being  the  latrines. 

In  natives,  the  forearms,  axillae  and  head  are  more  commonly 

attacked.     The  inflamed  area  is  about  three-quarters  of  an  inch 

in  diameter. 

Extract  the  larva  and  treat  antiseptically.     Some  require  a  long 

time  to  heal. 

(3)  Chrysomyia  macellaria  (Screw-worm). 
Common  in  America. 

The  insect  lays  a  mass  of  300  to  400  eggs  on  the  surface  of 
wounds,  in  the  ears  and  nasal  fossas  of  persons  sleeping  in  the 
open  air.     Offensive  discharges  will  attract  the  flies. 


PEDICULOSIS  483 

The  larvas  hatch  in  a  few  hours,  and  are  about  three-quarters 

of    an    inch    long,    with    twelve   segments    carrying   circles   of 

spirally    arranged     spines    giving    a     screw-like    appearance. 

These   burrow    into    and    devour   mucous    membrane,    muscle, 

cartilage,  periosteum,  bone,  and  may  even  reach  the  brain  and 

cause  death. 

Neglected,  the  patients  die;  treated,  they  live. 

Injections   of   chloroform,   carbolic   acid,    turpentine,    &c.,    are 

necessary. 

The    frontal    sinuses,    antrum,    and    other    bony    cavities    may 

require  opening  up. 

(4)  Auchmeromyia  luteola. 

A  keen  blood-sucker,   the  Congo   Floor   Maggot,   common   in 
Africa. 

The  larva  has  eleven  segments,  at  the  posterior  end  of  each  are 
three  short  limbs  provided  with  spines  directed  backwards; 
laterally  each  segment  bears  two  or  more  protuberances  with  a 
small  spine.  The  anterior  segment  bears  the  mouth  and  two 
black  hooks,  each  surrounded  by  minute  teeth.  After  feeding, 
the  semitransparent  body  appears  red  to  about  the  fifth  seg- 
ment as  a  result  of  the  blood  taken.  The  adult  fly  corresponds 
in  colour  Avith  the  smoke-stained  straw  of  native  houses ;  it  rests 
under  the  roof ;  is  silent ;  lays  its  eggs  in  the  cracks  of  the  mud 
floors,  under  native  mats,  and  in  soft  moist  earth. 
They  feed  at  night.  Those  sleeping  on  beds  and  raised  plat- 
forms escape  as  a  rule. 

NODULAR  LIPOMATOSIS. 

Innocent  fatty,   subcutaneous  nodules,    felt   under  the  skin,   which 
may  at  time  be  mistaken  for  enlarged  lymphatic  glands. 
No  treatment  is  necessary. 

PEDICULOSIS. 

A  condition,  exceedingly  common  in  the  Tropics,  resulting  from 
the  bites  of  Pediculus  humanis,  P.  corporis  and  Phthirius  pubis. 

The  latter  is  less  common  among  races  that  constantly  shave  the 
pubic  region. 

PATHOLOGY. 

The  mouth  parts  of  the  parasite  consist  of  a  double  tube,  one  inside 
the  other.  The  outer  chitinous  tube  or  proboscis  is  a  fused  labrum 
and  labium  armed  with  minute  curved  booklets. 

The  inner  membranous  or  suctorial  tube  consists  of  maxilla  and 
mandibles. 


484  DISEASES  OP  THE  SKIN 

When  biting  the  proboscis  is  inserted  into  a  sweat  duct,  the  small 
booklets  everted  and  the  skin  thus  gripped ;  the  suctorial  tube  is  then 
protruded  until  it  reaches  blood,  the  salivary  glands  at  the  same  time 
inject  their  venom  causing  the  pruritus;  the  pharyngeal  pump  draws 
blood,  the  parasite  falls  off  leaving  a  minute  red  spot  and  marked 
itching.  This  area  is  vigorously  scratched  and  pyogenic  infection 
may  follow.  This  condition,  when  constant  with  some  thickening  of 
the  skin  and  pigmentation,  is  known  as  "vagabond's  disease." 

The  parasites  secrete  themselves  in  the  folds  of  the  clothing, 
especially  about  the  seams,  and  later  attack  the  hairy  parts. 

The  eggs  are  attached  to  the  hairs. 

TREATMENT. 

Shave  off  the  hair  and  apply  calamine  lotion,  or 

Soak  the  hair  in  petroleum,  wash  with  soap  and  water  every  twenty- 
four  hours,  or 

Apply  sulphur  and  resorcin  ointment,  wash  with  soap  and  water, 
soak  in  acetic  acid,  25  per  cent.,  comb  with  a  tooth-comb  to  remove 
the  eggs,  and  Avash  again. 

All  clothing  must  pass  through  steam  sterilizers. 

Antiseptic  baths  and  calamine  lotions  are  always  useful. 

PEMPHIGUS  CONTAGIOSUS   (Pyosis  mansoni). 

A  non-febrile,  highly  contagious  disease  of  warm  countries,  charac- 
terized by  large  vesicles  or  bullae  without  inflammation  or  ulceration. 
The  fluid  is  clear,  then  turbid ;  the  blister  ruptures ;  exfoliation  of  about 
one  inch  of  skin  takes  place,  and  a  pinkish  scar  forms.  It  may  attack 
any  part  of  the  body,  but  in  adults  the  axillae  and  groin  regions  are 
usually  selected. 

The  causative  organism  has  not  been  proven ;  it  is  probably  a 
pyogenic  organism. 

Keep  the  parts  clean  and  dry.     Use  dusting  powder  of  boric  acid, 
zinc  oxide  and  starch,  equal  parts.     Mercuric  lotions  should  be  used- 
Iron,   arsenic  and   strychnine   internally. 

PYOSIS  CORLETTI  (1915). 

An  epidemic  eruption  of  bulla  amongst  English  soldiers  in 
Khartoum,  probably  identical  with  Corlett's  "  Impetigo  contagiosa 
bullosa  "  in  American  soldiers. 

Bulla  arise  from  apparently  sound  skin  without  fever  or  pruritus- 
and  spread  over  the  whole  body  and  limbs. 

A  diplococcus  (Amococcus  mollis)  is  always  found. 

The  soles  are  not  attacked,  there  are  no  crusty  lesions,  and  strepto- 
cocci are  absent.  It  does  not  select  moist  folds  of  skin,  and  is  not 
surrounded  by  an  inflammatory  zone. 


PENICILLIOSIS  485 

Autogenous  \accines  and  local  antiseptics  cure  the  condition. 
Isolation  is  necessary  to  stop  the  epidemic. 

PENICILLIOSIS. 

The  hairs  of  the  moustache,  beard,   or  axilhe  are  attacked  by  the 
fungi,    Penicillium   barbae,    and    Aspergillus   barbie  =  Aspergillosis. 
The  condition  tends  to  become  chronic.     The  diagnosis  is  easy. 
The  treatment  is  as  for  pediculosis. 

PHAGED^ENA  (Tropical  Sloughing  Phagedaena). 

It  is  a  rapidly  spreading  gangrenous  condition  of  the  skin  and 
subcutaneous  tissues,  forming  a  large  sloughing  sore  which  ultimately 
ceases  to  spread,  and  cicatrizes  or  remains  as  a  chronic  ulcer.  Men, 
physically  depressed  from  other  causes,  are  generally  attacked,  such 
as  slaves,  prisoners,  soldiers,  pioneers,  &c. 

Any  small  injury  or  ulcer  may  develop  into  one. 

There  is  a  large  bleb  which  ruptures,  exposing  a  foul,  moist 
slough,  which  extends  in  all  directions.  The  deeper  structures  are 
generally  spared,  but  deformitv  alwa3's  results  if  the  victim  lives. 

Saprasmia  and  exhaustion  or  the  rupture  of  a  large  blood-vessel 
will  carry  off  the  patient.     Pyogenic  organisms  have  been  found. 

The  bacillus  of  Vincent  and  an  associated  spirillum  are  commonly 
found. 

Correct  the  general  health,  give  nourishing  fresh  food  and 
vegetables,  opium  and  general  tonics. 

Cauterize  the  part  under  chloroform,  irrigate  continuously  until 
healing  takes  place. 

Consider  the  patient  as  infective  and  isolate  him. 

PIEDRA. 

A  mycotic  disease  of  the  hair  found  in  South  America,  especially 
Colombia,  consisting"  of  one  or  more  liard  small  nodosities  on  the  hair 
caused  by  Trichosporon  giganteum.  The  affected  hairs  are  bent, 
twisted  and  matted  together.  The  node)silies  arfe  groups  of  spores 
around  the  hair,  leaving  the  latter  intact. 

They  can  be  seen  with  a  microscope  after  washing  with  ether  and 
soaking  in  liq.  potass. 

Bathe  the  hair,  sponge  with  salicylic  acid  in  absolute  alcohol, 
5  per  cent. 

This  is  good  for  the  long  hair  of  women. 

Otherwise  treat  as  for  Pediculosis. 

PINTA   (Carate). 

A  group  of  allied  epiphytic  diseases  of  the  skin  common  in  Tropical 
America,  characterized  by  pigmented  areas  of  skin,   varving  in   tint, 


486  DISEASES  OF  THE  SKIN 

and  caused  by  more  than  twenty  species  of  the  fungi  :  Aspergillus, 
Penicillium,   Monilia  and  Montoyella. 

It  is  contagious,   but  Europeans  are  rarely  attacked. 

The  Aztecs  of  Peru  prayed  about  it  centuries  before  the  Spanish 
conquest. 

SYMPTOMS. 

There  is  desquamation  and  itching  of  the  patches,  the  first  of  which 
may  be  red,  white,  blue  or  black,  the  varying  tints  being  due  perhaps 
to  the  variety  of  the  fungus. 

When  the  scalp  is  affected  the  hair  turns  grey,  becomes  thin  and 
falls  out.  One  person  may  show  different  tints,  but  the  patches  them- 
selves do  not  change  in  colour. 

The  superficial  type  is  usually  blue  or  black  and  spreads  rapidly. 
The  deep  type  is  usually  red  or  white  and  spreads  slowly,  and  is  more 
difficult  to  cure. 

TREATMENT. 

Destroy  all  old  clothes.     Absolute  cleanliness. 

Apply  chrysophanic  acid,  sulphur,  resorcin,  liniment  of  iodine  or 
other  epiphyticides. 

PITYRIASIS. 
P.  versicolor. 
See  Tinea  versicolor. 
P.  rubra. 
See  Dermatitis  exfoliativa. 

PRICKLY  HEAT. 

A  papular  or  papulo-vesicular  eruption  with  marked  pruritus  con- 
nected with  profuse  sweating  so  common  in  all  hot  climates. 

Anything  resulting  in  perspiration  in  hot  climates  may  cause  it. 

The  theories  of  its  causation  are  as  follows  :  — 

(i)  Sodden  cells  of  sweat  glands  swell  and  obstruct  the  orifice  of 
the  sweat  duct  (Pollitzer). 

(2)  Acute  distension  of  sebaceous  glands  by  their  own  secretion 
(Pearse). 

(3)  An  infective  disease  caused  by  a  very  minute  but  active  amoeba 
(Durham). 

Numbers  (i)  and  (2)  may  both  be  present,  and  infection  is  not  at 
all  improbable  through  scratching. 

The  disorder  is  not  serious  in  robust  people,  but  to  weaklings  it 
may  be  serious  from  loss  of  sleep,  &c. 

TREATMENT. 

Avoid  all  causes  of  excessive  perspiration. 
Avoid  copious  drinks  and  all  alcoholics. 


PSORIASIS 


487 


Avoid  warm  and  irritating  clothing  and  close  rooms;  silk  clothing 
may  be  necessary. 

Apply  spirit  lotion  to  the  skin;  antiseptic  baths;  antiseptic  dusting 
powders,  e.g.,  boric  acid,  zinc  oxide  and  starch,  equal  parts. 

Calamine  lotion  is  soothing. 

Keep  the  bowels  active  with  salines. 

For  spirit  lotion  use  :  — 

^     Acid,  salicyl i   drachm 

Spirit,  rect.    ...  ...         8  ounces 

Followed  by  dusting  as  above. 

PSORIASIS. 

A  chronic  recurring,  dry,  patchy  eruption  of  unknown  origin, 
occurring  most  frequently  about  the  elbows  and  knees,  characterized 
by  silvery  scales. 

The  general  health  is  but  slightly  affected. 

It  is  usually  seen  in  young  adults. 

It  is  frequent  among  Europeans  but  rare  among  tropical  races. 

Irritation  of  the  skin  should  be  avoided.  Arsenic  should  be  given 
internally.  Fowler's  solution  is  most  useful,  3  minims,  t.d.s., 
increased  gradually  when  tolerated,  to  minims  10,  t.d.s. 

Locally  :  Remove  scales  with  salicylate  acid  spirit  6  per  cent,  and 
treat  when  there  is  marked  hyperjemia  present  with  ung.  hydrarg. 
ammon.  or  chrysarobin,   10  to  20  grains  to  one  ounce. 


ment  is  usetui  :  — 

^     Acid,  salicyl 

.     10  parts 

Olei  ricin 

.     20      „ 

Chrysarobini    ... 

.     20      „ 

Sapon.  virid 

.     25      „ 

Vaseline  flavi  ... 

.     25      „ 

PYOSIS  PALMARIS. 

There  are  numerous  discrete  conical  white  pustules  on  the  palms, 
■containing  the  ordinary  pyogenic  cocci,  but  not  surrounded  by  any 
marked  inflammation.  The  cause  is  unknown,  and  treatment  is  not 
•encouraging  according  to  Castellani. 

SCABIES. 

Ten  days  or  more  after  the  female  acarus  (Scabiei  hominis)  has 
.entered  the  skin  a  small  vesicle  appears  usually  between  the  fingers  or 
toes,  occurring  amongst  dirty  people  and  those  working  amongst  such. 

There  is  much  itching,  especially  at  night;  secondary  infection  is 
■common. 

Sulphur  ointment,  vigorously  rubbed  in  every  few  hours  for  several 
days,  followed  by  an  antiseptic  bath,  clears  up  the  condition. 

The  clothes  should  be  boiled  and  sterilized. 


488  DISEASES   OF   THE  SKIN 

Balsam  of  Peru  is  also  fatal  to  the  acariis.  Paint  the  part  affected 
and  leave  it  on  for  one  night. 

SEBORRHGEA. 
This  condition  is  common  amongst  Europeans  in  the  Tropics. 
It  occurs  especially  about  the  chest. 
Sulphur  ointment  about  5  per  cent,  will  clear  it  up. 

SKIN  PIGMENTS. 

Skin  pigment  is  a  mixture  of  black,  yellow  and  red  pigments. 

A  "white"  skin  may  average  a  mixture  of  pigments  as  follows; 
black,  8;  yellow,  9;  red,  50;  white  or  absence  of  pigment,  t,t,  per  cent. 

A  "black"  skin  mav  average  a  mixture  as  follows:  black,  68; 
yellow,  2  ;  red,  26;  white  or  absence  of  pigment,  4  per  cent. 

These  tints  can  be  obtained  by  blending  them  on  a  rotatory  disc. 

SPOROTRICHOSIS. 

There  are  subcutaneous  nodules  ^hich  soften  in  two  to  three 
months,   forming  abscesses  discharging  a  greyish  yellow  pus. 

The  disease  is  caused  by  eight  species  or  more  of  the  fungus 
Sporotrichum.  This  fungus  is  readily  cultured  on  Sabouraud's 
glucose,  this  being  the  best  means  of  differentiating  the  disease  from 
Tuberculosis,   Syphilis,   Glanders  and   Blastomycosis. 

The  condition  is  ver}-  chronic  and  requires  vigorous  treatment. 

Puncture  the  nodules  in  the  early  stages  and  inject  i  per  cent,  of 
iodine  solution.     Give  iodides  internally  in  all  cases  in  large  doses. 

The  disease  rapidly  disappears  under  iodine  treatment. 

Appl\-  antiseptic  dressings  to  ulcers.  Operative  surgical  measures 
are  not  necessary. 

SYPHILIS. 

This  is  very  prevalent  in  all  its  phases.  It  should  not  be  confused 
with  frambcx'sia  iro]3ica.     Treat  as  in  luirope. 

TATTOOING  (tattoo  -.  marking). 

The  formation  of  indelible  skin  marks  resulting  from  the  insertion 
of  pigments  into  slight  or  deep  wounds.  The  term  "  tattoo  "  is  also 
applied  to  the  skin  fu.ri'ows  or  "keloid"  so  commonh-  seen  in  African 
natives.  Tattooing  is  usually  intended  to  be  a  permanent  form  of 
decoration,  an  advancement  on  the  "painting"  of  uncivilized  peoples. 
Extensive  tattooing  is  very  painful  and  recjuires  \ears  to  complete 
elaborate  designs  as  little  can  be  done  at  a  time. 

Sometimes  several  weeks  are  required  for  Avounds  to  heal;  blood 
poisoning  and  even  death  has  resulted  from  the  process. 

The  designs  seen  amongst  Europeans  and  Asiatics  probablv  come 
from  the  Japanese,  amongst  whom  it  was  introduced  over  300  years 
ago.     Charcoal  and  vanilla  are  the  most  common  pigments. 


TINEA    (RINGWORM)  489 

TREATMENT. 

Small  marks  can  be  excised.  Blistering  and  Finsen  light  has  been 
used.  Carbon  dioxide  snow  leaves  a  scar.  When  gunpowder  is  used 
paint  with  di-iodide  of  ammonium,  followed  by  dilute  HCl. 

Persistent  application  of  dilute  acids  and  dilute  alkalies  may  be 
effectual,  but  it  is  a  tedious  and  painful  process,  eventually  leaving 
a  scar. 

Only  a  prolonged  dermatitis  will  remove  extensive  tattooing. 

TINEA  (Ringworm). 

A  contagious  inflammatory  infection  of  the  skin  affecting  the  hair, 
nails  and,  rarely,  mucous  membrane,  caused  by  one  of  the  fungi  to  be 
enumerated  later. 

Ringworm,  which  is  derived  from  animals,  is  usually  more  inflam- 
matory than  that  of  human  origin. 

The  appearance  of  the  lesion  varies  according  to  the  part 
aftected,  as — 

(i)  The    hairy    parts,    e.g.,    the    scalp  =  tinea    tonsurans,    so-called 
because    it    resembles    in    outline    the    priestly    tonsure;    tinea 
barbae,   sycosis  and  palpebralis. 
(2)   The  non-hairy  parts,  e.g.,  the  body  =  tinea  circinata,  the  nails 
^  onychomycosis,    the    mucous    membranes    of    the    mouth, 
vulva,   inguinal,  perineal  and  gluteal  regions  =  T.  marginata 
(eczema  marginatum). 
There  are  two  families  of  ringworm  fungi  :  — 
(i)  Trichophytons  (large  spores)  (6'/?^^=  hair,  0i;toj^  =  fungus). 
(2)  Microsporons  (small  spores). 

Of  these  there  are  many  species  of  clinical  interest  which  will  be 
dealt  with  seriatim  later. 

DIFFERENCES  BETWEEN 
Trichophytons  and  Microsporons. 

Large-spored  tinea  Small  spored  tinea 

Square  or  oblong  Round  or  ovoid 

Arranged  in  regular  chains  No  definite  arrangement 

Regularly  jointed,  short,  mycelium  Mycelium      irregularly     jointed,    curved 

and  branching 
Fungus   first  attacks  root  and  grows  up-  Fungus   lies  about  the  hair  as  a  visible 

wards,  breaking  the  hair  off  short  greyish  sheath,  destroys  the  shaft  and 

eats  down  to  the  root 

The  lesion  commences  in  the  epidermis  in  both  cases. 
The  Endothrix  tinea  develops  exclusively  within  the  hair  structure, 
Endo-ectothrix  tinea  develops  within  the  hair. 


490  DISEASES   OF  THE  SKIN 

EPITOME  OF  ETIOLOGY  (Morris). 

Tinea  tonsurans  is  mostly  due  to  M.  audouini  and  to  the  endothrix 
trichophytons,  but  the  scalp,  and  especially  the  juvenile  scalp,  may  be 
attacked  by  a  great  many  of  the  fungi  of  both  families. 

The  beard  is  attacl'ced  by  trichophytons  only. 

The  hairless  skin  is  seldom  affected  by  microsporons. 

The  nails  are  rarely  involved ;  in  such  cases  the  parasite  is  the 
T.  acuminatum  or  T.  violaceum. 

Adults  are  scarcely  ever  attacked  except  by  endo-ectothrix  tricho- 
phytons, which  group  is  also  responsible  for  much  of  the  ringworm 
of  the  hairless  parts. 

VARIETIES. 

(1)  T.  alba. 

Parasite,  T.  macfad3'eni. 

Attacks  the  arms,  legs  and  any  part  of  the  body. 

Lesions  are  white,  oval  or  irregular  patches,  margins  slightly 

elevated  and  sometimes  dotted  with  papules. 
It  is  a  form  of  dhobie  itch. 
Treatment. — Chrysarobin  ointment,  2*5  per  cent.,  and  tincture 

of  iodine. 

(2)  T.  albigena. 
Parasite,  T.  albicans. 

Attacks  the  palms  and  soles  especially,  also  the  nails,  forearms 

and  legs. 
Lesions,  bullae  which  rupture,  followed  by  a  profuse  keratosis 

until  the  palms  and  soles  thicken  considerably. 
White  patches  may  develop  on  the  leg  and  arm. 
Treatment  as  above. 

(3)  T.  barbae  (Sycosis). 

Parasite,      endo-ectothrix      trichophytons     from     animals      or 

children,  shaving  brushes,  &c.,  less  often. 
T.   acuminatium,    violaceum   and    nodoformans. 
Attacks  the  beard  area,  mostly  confined  to  young  male  adults. 
Lesions,    itching,    chronic,    scaly   eruption,   sometimes   gyrated 

or  pustular.     In  simple  cases  the  hair  is   not  damaged ;   in 

severe  cases  the  hair  is  permanently  destroyed. 
Treatment. — Perseverance  is  essential  for  a  cure. 
X-rays  where  possible  if  there  is  no  suppuration. 
Epilation  with  forceps. 
Chrysarobin  and  sulphur  ointment. 
All  barber's  instruments  to  be  sterilized  thoroughlv  each  time 

thev  are  used. 


TINEA    {RINGWORM)  •     491 

(4)  T.  capitis  (tonsurans). 

Parasite,  Trichophytons  violaceum,  T.  sudanense,  T.  poly- 
genum,  T.  exsiccatum,  rarely  also  Microsporons. 

Incubation  under  two  weeks. 

Attacks  the  scalp. 

Lesions,  patches  increase  in  size  surrounded  by  an  erythema- 
tous zone,  sometimes  vesicles  appear,  the  patch  is  studded  by 
broken  hair  stumps  and  debris  at  the  roots,  making  the 
epidermis  to  resemble  "goose-skin." 

A  serious  suppurative  variety  is  known  as  "kerion,"  when 
the  pus  in  the  follicles  loosens  the  hairs,  but  sloughing  never 
occurs.     The  patches  usually  remain  bald. 

Treatment. — X-rays,  epilation  by  forceps,  turpentine  oil, 
tincture  of  iodine  and  weak  chrysarobin  ointment,  2  per  cent. 

(5)  T.  circinata  (Ringworm  of  the  Body). 

Parasite,   usually  Trichophytons,   rarely  Microsporons. 

Attacks  the  face,  neck,  hands  and  wrists  most  frequently. 

Lesions,  a  small  red  spot  enlarged  in  a  ring  form  and  may 
reach  a  considerable  size,  or  several  small  coalesce  and  form 
festooned  patterns.  Sometimes  the  diagnosis  is  not  easy  but 
the  presence  of  the  fungus,  when  found,  is  conclusive. 

Treatment,  remove  superficial  epidermis  by  iodine  or  liquor 
epispasticus.  This  may  destroy  all  the  fungi.  It  is  best  to 
follow  it  up  with  ointment  as:  — 

1^     Chrysarobin  ointment 

Salicylic  acid         

Ichthyol 
Unguentum  simplex 

(6)  T.  cruris  (Eczema  marginatum,  Dhobie  Itch). 

Parasite,  Epidermophylon  inguinale,  peculiar  to  man,  widely 
distributed  in  the  tropical  and  sub-tropical  countries.  The 
term  "dhobie  itch"  is  loosely  used  in  the  East  for 
epiphytic  skin  diseases  which  are  supposed  to  be  contracted 
from  clothes  returned  by  the  dhobie  or  washerman. 

Attacks  pubic,  anal,  perineal,  axillary  and  other  regions  where 
skin  folds  are  in  contact,  e.g.,  interdigital  folds.  It  never 
attacks  hair  but  remains  in  the  stratum  corneum. 

Lesions  have  a  broad,  well-defined  margin,  scaly  and  papular. 
They  may  assume  an  eczematoid  character.  Pruritus  is  con- 
siderable and  pyogenic  infection  common. 

Treatment  :  — 


5 

parts 

2 

)i 

5 

') 

00 

n 

]?^     Chrysarobin 


Ichthyol 

Ungent.  zinc  oxide 
Acid  salicylic. 
Vaseline  ... 


)> 


...     20 

4  drachms 
8  grains 
I  ounce 

Apply  morning  and  evening  for  fourteen  days. 


20  grams 


492  DISEASES   OF  THE  SKIN 

(7)  T.  decalvans. 

An  anomalous  form  of  mirrosporosis  of  tlie  scalp  or  bald  ring- 
worm. The  hair  falls  out,  leaving  a  bare  patch  in  a  place 
previously  unaffected  or  on  an  ordinary  ringworm  area.  The 
scalp  is  affected  and  the  lesion  resembles  alopecia  areata. 

(8)  T.  flava. 

Parasite,   Malassezia  tropica  (Castellani,   1905). 

It  is  very  common  in  all  tropical  countries. 

The  mycelial  threads  are  thick  with  numerous  swellings  and 
constrictions.  The  spores  are  rounded  or  oval  and  have  a 
double  contour,  and  often  run  into  clusters.  In  chronic  cases 
the  fungus  is  not  so  readily  found.  It  is  common  amongst 
the  Russian  poor. 

Attacks  face,  neck,  chest  and  abdomen. 

Lesions  begin  as  tiny  spots,  slowly  enlarging,  the  tint  varying 
from  deep  orange  yellow  to  deep  canary  yellow.  There  is  no 
itching  or  descjuamation.     It  tends  to  be  very  chronic. 

These  "  beauty  "  spots  are  liighly  appreciated  by  some  natives. 

Treatment. — Patience  and  perseverance  are  necessary  for 
months. 

A  cold  climate  hastens  the  process  of  cure. 

Apply  turpentine  daily.     For  exposed  parts  use  :  — 

^     Resorcin     i  drachm 

Salicylic  acid         10  grains 

For  covered  parts  use  :  — 

Chrysarobin  20  per  cent.,  or  tincture  of  iodine. 

(9)  T.  imbricata. 

A  form  of  body  ringworm  formerly  peculiar  to  the  East,  but 
now  rapidly  spreading  in  damp  equable  climates  of  70°  F. 
to  90°  F. 

It  is  produced  by  a  trichophyton,  and  characterized  by  a 
concentric  arrangement  of  closely  set  rings  of  scaling 
epidermis  (Manson).     It  is  not  known  in   Africa. 

Parasite,  Endodermophyton  concentricum  and  E.  indicum 
(Castellani). 

Incubation,    nine  da}s. 

Attacks  the  whole  body,  but  avoids  hairy  parts,  especially  the 
scalp.     The  nails  may  be  affected. 

Lesions  commence  as  spots  and  develop  into  concentric  rings 
of  tissue-paper-like  scales  about  i  inch  a)5art  and  having  one 
free  edge.  Itching  is  generallv  intense,  but  the  general 
health  is  unaffected.  The  condition  tends  to  become  chronic 
without  spontaneous  recoyer\-.     Relapses  are  common. 


TINEA    (RINGWORM)  493 

Treatment. — Strong  iodine  liniment  or  :  — 

i\     Resoicin     2  drachms 

"  Tinct.  benz.  CO i  ounce 

Or,  Chrysaiobin  ointment  5  per  cent.,  but  it  is  necessary  to  examine  the  urine 
and  watch  the  patient. 

Continue  for  weeivS.     Improvement   is  frequently   followed  by 

relapse. 

(10)  T.  intersecta. 

Parasite,  Kndodermophyton  castellani,  found  on  the  inner 
surface  of  the  scales;  the  mycelia  are  abundant,  but  spores 
are  rare.  The  former  are  long,  straight,  articulated  threads 
without  fructifications. 

Attacks  the  arms,  legs,  chest  and  back. 

Lesions  commence  as  small,  round,  elevated,  ilchy  patches, 
with  minute  black  papules  about  the  border.  Several  may 
coalesce.  They  are  at  first  tense,  then  shrivelled,  cracked 
with  white  lines  on  the  dark  sur'face.  The  cracks  deepen 
and  the  scales  are  formed. 

Treatment. — Apply  sulphur  and  chrysarobin  ointments. 

(11)  T.  nigra. 

Parasite,  Cladosporium  mansoni,  abundant  in  the  lesions. 
The  mycelia  are  short,    bent,   often   banana-shaped   with    large 

spores. 
T.  flava  may  co-exist  with  it. 
Attacks  any  part  of  the  body  except  the  face,   usually  on  the 

neck  and  chest. 
Lesion  is  black,  lustreless,  with  but  little  pruritus. 
Treatment. — Easily  curable  except  on  the  palms. 
Small  patches  yield  to  40  per  cent,  formalin. 
Large  patches  to  salicylic-alcohol  lotion,  2  per  cent. 
Later  apply  resorcin  ointment. 

(12)  T.  nigro-circinata. 

Parasite,    Trichophyton    cevlonese.      It    has    large    spores,    not 

numerous,  having  a  double  contour. 
Attacks  the  neck  and  scrotum. 
Lesion,  black  rings  with  thick  elevated  margins. 
Treatment. — Spontaneous    healing    is    common,    leaving    dark 

patches. 

Apply  tincture  of  iodine. 

(13)  T.  nodosa  (Morris). 

A  nodular  concretion  containing  a  fungus,  and  its  spores 
affecting  the  hair  of  whiskers,  beard  and  moustache.  The 
affected  hairs  split  and  break.  It  is  not  to  be  confused  with 
piedra  due  .to  T.  giganteum. 

Cut  the  hair  short  and  use  antiparasitic  remedies. 


494  DISEASES   OF  THE  SKIN 

(14)  T.  palpebralis. 

A  rare  form  of  ringworm  that  attacks  the  eyebrows  usually  by 
spreading  from  the  face. 

(15)  T.  sabouraudi  tropicalis. 

Parasite,    Trichophyton   blanchardi ;   cultures   of   it   cannot   be 
grown . 

Attacks  the  legs. 

Lesions   commence    by    erythematous   patches   covered   with 
small  pityriasic  squama,  later  there  is  a  circinatiform  appear- 
ance   with    a    dark    brown    base.     Pruritus    is    marked.     In 
chronic  cases  there  is  thickening  of  the  skin. 

Treatment. — A  cold  climate  causes  it  to  disappear. 

Apply  chrysarobin  ointment,  2  per  cent,  to  4  per  cent. 

(16)  T.  ungium. 

Parasite,    Epidermophytons,    Trychophyton    and    Endodermo- 

phytons. 
Attacks  the  nails  of  the  fingers  and  toes. 
Lesions  cause  discoloration  of  the  nails,  brittleness,  roughness 

and  splitting  of  the  free  border. 
Treatment  is  difficult. 

Soften  the  nails  by  rubbing  in  liquor  potassium. 
Apply  wet  dressings  of  hyposulphite  of  soda  or 

-^     Pot.  iodid.  ...         ...         ...         ...     lo'oo    grammes 

Iodine         ...         ...         ...         ...       i"oo  „ 

Water,  ad.  ...         ...         ...         ...       i"ooo  c.c. 

If    the   accompanying   condition    is   due   to   T.    imbricata,    use 

resorcin  in  tincture  of  benzoin,   i  in  16. 

(17)  T.  versicolor  (Pityriasis  versicolor) . 

Parasite,    Microsporon    furfur;   cultures   are   grown    with    diffi- 
culty.    The  double  contour  spores  are  found  in  clusters. 
Attacks  the  trunk  usually,  less  frequently  the  arms  and  face. 
Lesions    are    rounded,    slightly    raised,    scaly   patches    with    a 
well-defined  border,   often  fused,   of  a  brownish   tint,   some- 
times black.     Pruritus  is  marked. 
Treatment. — Spontaneous  cure  ultimately. 
Wash  with  soft  soap  and  warm  water. 
Apply  tincture  of  iodine. 

Naphthol  ointment,   i   in  39,  or  sulphur  ointment,   i   in  20,  are 
efficacious. 

TRICHOMYCOSIS. 
A  nodular  affection  of  the  hair,  generally  of  the  axillary  regions, 
caused  by  a   Nocardia  which   closely   resembles,    but   is   not   identical 
with  Leptothrix.     The  affected  hairs  have  soft  thickenings  of  yellow, 
black  or  red  colour,  easilv  removed  from  (he  hair. 


TUMOURS 


495 


Formalin  in  spirit  will  clear  it  up,  i  in  30. 
Apply  sulphur  ointment  at  night,  4  per  cent. 
The  principal  nodular  concretions  of  the  hair  are  :  — 
(i)  Nodular  trichomycosis. 

(2)  Piedra  (trichosporosis  tropica). 

(3)  Tinea  nodosa. 

TRICHONOCARDIASIS   (Nodules  on  the  Hairs). 

See  above  remarks. 

TUMOURS. 
(1)  Benign  epithelial  tumours. 

Epithelial  moles  are  frequent. 

Hyperkeratosis  is  common  in  all  barefooted  tribes. 


Molluscum  fibrosum.     (By  C.  C.  Elliott,  Paoning.) 
Before  operation.  After  operation. 

Molluscum  contagiosum  is  not  infrequently  met  with. 
Verruc^e  are  extremely  common. 
Warts  are  very  common. 

(2)   Malignant  epithelial  tumours. 

Melanotic  carcinoma  is  rare,  but  has  been  seen  in  half-castes. 
Paget's  disease  of  the  nipple  is  rare. 
Rodent  ulcer  is  rarely  seen. 


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DLSiiASliS   (>/•"    / ///:    .S7\7.\ 


(3)   Benign  connective  tissue  tumours. 
.\ni,n()niatc-i  arc  fairl\-  conimon. 
Fibroma     mollusciini     or     neurolibrosis 

common. 
I'""ibroma  pendulum  and   l-\  sinj^le  are  common. 

i'llaslorrhexis         or 


of     Recklinghausen, 


Molluscum   tibrosum. 
(By  M.  Mackenzie,  P'oochow.) 


pseudo- 
xanthoma   has   been    seen    in 
half-castes. 
Cheloid   is  extremely  common  ; 
ii  follows  tattooing  in  African 
natives   and    hypodermic    in- 
jections in  Chinese. 
L\  nii^hangiomata  are  very  fre- 
quent. 
Multijile     telangiectasis     some- 
what common. 
Myomata  are  rare. 
Xanthoma  diabeticorum  is  com- 
mon in  India  and  Ceylon. 
Xanthoma  planum   and   tubero- 
sum are  fairly  frequent. 
4)   Malignant       connective       tissue 
tumours. 
L\mplioderma  perniciosum  has 

been  seen. 
Mycosis    fungoides    has    been 

seen  in  a  half-caste. 
Angio-sarcoma  is  to  be  fotind 

in  the  Cameroons. 
Multiple  sarcomatosis  is  rare. 
The  author  has  seen  carcinoma 
of  the  cervix  and  of  the 
pvloris  in  Colombia,  South 
America,  and  carcinoma  of 
the  ovarv  in  Central   Africa. 

ULCERATIONS. 

ihc  majority  of  tropical  idcera- 


tions  are  (he  residt  of  some  trivial 
scratch  or  bruise,  but  as  a  residt  of  neglect,  underfeeding,  moistness 
of  the  skin,  exjx)sure  and  liability  lo  secondary  infections,  ulcers  of 
enormous  dimensi(jns  may  develop.  In  some  cases  the  writer  has  seen 
both  tibia  and  llbula  of  the  same  leg  exposed  on  two  sides  by  ulcera- 
tions, the  vessels  and  nerves  remaining  isolated  like  strings  plainly 
visible. 


ULCERATIONS 


503 


Various  methods  have  been  employed  for  the  naming  of  ulcers  as- 
Local  names,  e.g.,  veldt  sore. 
Anatomical  names,  e.g.,  interdigital. 
Age,  e.g.,  infantile. 

General  disease,  e.g.,   leprotic  or  elephantoid  ulcers. 
Local    pathogenic    condition,    e.g.,    varicose    ulcer,     ulcerating 
granuloma. 


Sarcoma  of  the  Buttock. 

It   will   suit   our  purpose   to   use   the   alphabetical   classification    of 
common  terms  employed. 

Blastomycotic,  see  Blastomycosis. 
Cancerous,  same  as  in  temperate  climes. 

Diphtheroid,     has    grey    or    blackish     re-forming     membrane, 
usually  on  the  legs. 


504 


DISEASES  or  Tin-   SKIS 


Elephantoid,   see   I-'lephantiasis. 
Framlxvsial,  see  I'rambccsia  tropica. 
Gangosa,  see  Gangosa. 
Glanders,  same  as  in  temperate  climates. 
Infantile,  usually  multiple  and  not  severe. 
Interdigital,  treat  as  for  septic  ulcers. 


Horny  growth  from  the  cheek. 
(I'robably  a  sebaceous  hum.) 

Leprotic,  see  Leprosy. 

Oriental  sore  and  espundia,  see  Leishmaniasis. 
Septic,  antiseptic  treatment. 
Syphilitic,  treat  the  constitutional  disease. 
Tubercular,  treat  the  tubercular  disease. 

Tropical,    generailv    chronic   and    sloughing;    spiroclvTtes    and 
Leishman-Donovan  bodies  have  been  found  in  them. 


ULCERATIONS 


505 


Ulcerating  granuloma,  see  article  on. 
Varicose,  common  among  young  rickshaw  coolies. 
Veldt  sore,  a  septic  ulcer  common  during  the  Boer  War. 
Ulcerations  which  are  manifestations  of  general  diseases  must  be 
treated  accordingly;  ulcers  of  local  origin  are  dealt  with  according  to 
their  severity  by  antiseptic  lotions,  powders,  ointments,  cauterizations 
and  other  operations. 

Fomentations  to  clean  them  up,  assisted  by  petroleum  washings 
if  necessary,  followed  by  cleansing  lotions  of  corrosive  sublimate, 
lysol,  cyllin,  potassium  permanganate,  oxygen  peroxide,  boric  lotion, 
eusol,  followed  by  antiseptic  dusting  powders  such  as  iodoform,  i  ; 
talc,  I  ;  boric  acid,  2. 


Chondroma.     (By  P.  B.  Cousland,  Swalow.) 

Some  may  require  cauterization  by  silver  nitrate,  pure  carbolic,  or 
the  actual  cautery;  others  may  require  scraping  and  cauterizing  under 
anaesthetic;  some  may  require  excision,  others  X-ray  treatment. 

Bier's  passive  congestion  has  not  proved  useful  in  the  author's 
experience. 

Rest,  nourishing  food,  correction  of  other  disorders  and  the  best 
hygienic  conditions  will  hasten  the  process. 

VESICULAR  DERMATITIS. 

An  epidemic  dermatitis  occurring  at  Leopoldville,  Congo,  caused 
by  a  small  beetle  of  the  genus  Polderus.  There  may  be  vesicles  on 
an  ervthematous  patch  or  on  long  streaks  with  inflamed  borders. 


5o6  DISEASES   Of  THE  SKIN 

The  initial  erythema  of  twenty-four  to  forty-eight  hours  is  followed 
by  the  vesicles  which  soon  become  mucopurulent,  persisting  for  four 
or  five  days,  and  ending  in  desquamation.  Europeans  are  affected  on 
the  uncovered  parts. 

The  beetle  is  crushed  by  tlir  vie  (ini  and  the  secretions  ri:bbed  into 
skin  (Rddhain  and  Iloussiau). 

XANTHODERMA    AREATUM. 

Clusters  of  yellow  spots  about  the  lower  part  of  the  legs  which 
coalesce,  forming  a  large,  irregular,  unraised  patch.  The  disease  is 
purely  local  and  not  of  a  serious  nature,  although  it  is  chronic. 

Resorcin  ointment  assists  the  condition. 


SECTION  VII. 
DISEASES   OF   THE    EYE. 

GENEREAL  REMARKS. 

BLINDNESS. 

LOCAL   DISEASES   OF   THE   EYE. 

CATARACT. 

OCULAR   MANIFESTATIONS   OF   GENERAL   DISEASES. 

THE   TREATMENT   OF   EYE   DISEASES. 


5o8  D  IS  RASES  01-  THE  EYE 


DISEASES     OF     THE     EYE. 

(;i:\i-:i<.\i.  ki:m.\kks. 

\Vk  do  not  projiose  to  consider  the  subject  in  detail,  but  only  to 
mention  those  disorders  of  tlie  eye  that  are  more  or  less  confined  to 
the  Tropics  or  are  met  with  in  an  ajj^ij^ravated  form  or  with  greater 
frequencv  than  elsewhere.  For  example,  quinine  amblyopia  and  the 
advanced  pathological  conditions  of  the  eye  in  leprosy  are  more  or 
less  confined  to  the  Tropics,  and  conjunctivitis  is  more  common  than 
in  an\  other  jiari  of  the  wcirlcl.  due  to  the  filthy  dwellings  and  habits, 
the  prevalence  of  dust  and  fly  carriers,  and  the  higher  temperature 
favourable  for  bacterial  development. 

HLIXDXESS. 

Blindness  is  very  ct)mmon  in  the  Tropics. 

In  India  (1901)  there  were  twelve  blind  men  and  twelve  blind  women 
in  every  !o,fxx)  adults  of  each  sex,  while  for  the  same  period  and 
number  there  were  in  I*!ngland  eight  blind  men  and  seven  blind 
women. 

The  causes  are  (tflen  due  to  the  neglect  of  slight  injuries  followed 
by  septic  infection. 

Dr.  \'ell  has  classified  the  causes  of  blindness  thus:  — 

(1)  Congenital,  e.g.,  syphilitic  affections  of  the  optic  nerve,  retina 
.111(1  choroid,  malformations  of  the  eveball. 

(2)  Local  Eye  Diseases,  e.g.,  ophthalmia  neonatorum,  purulent 
ophthalmia  in  adults,  catarrhal  and  granular  ophthalmia, 
ulccrati(m  of  the  cornea,  severe  paralyses  of  the  ocular  muscles, 
glaucoma. 

(3)  Traumatisms,  e.g.,  injuries  from  sticks  and  thorns,  exposure  to 
suniighi,  eclipse  iilindness.   night  blindness. 

(4)  Constitutional  Diseases,  e.g.,  .syphilis,  malignant  tumours, 
leprosy,   tuberculosis,   typhoid  fever. 

(5)  Drugs,  e.g.,  alcohol  (most  common),  tobacco  (rare),  quinine  and 
opium  (very  rare). 


LOCAL  DISEASES    OE    THE    EVE  509 

LOCAL  DISEASES  OF  THE  EYE. 

(1)  Traumatisms. 

Burns  and  scalds.  The  cornea  may  be  injured  and  slough. 
Enucleation  may  be  necessary.  If  by  lime  and  acids  there 
is  often  symblepharon.  To  treat  such  cases  insert  a  neutral 
oil,   as  castor  or  olive  oil. 

Foreign  bodies  such  as  pieces  of  steel.  Apply  2  per  cent, 
cocaine  and  remove  the  particle.  If  allowed  to  remain  in 
the  eye  it  may  become  encased  in  fibrous  tissue  and  followed 
by  vitreous  degeneration  and  opacity,  gross  pigmentation  of 
the  choroid,  iritis  and  optic  atrophy. 

Flies  may  carry  micro-organisms  and  cause  conjunctivitis. 

Abrasions  of  the  cornea  from  inverted  eyelashes  or  scratches 
from  baby's  finger   nails,   &c. 

Contusions  and  concussion  injuries  (black-eye).  Such  may  be 
followed  by  mydriasis,  rupture  of  the  ball,  dislocation  of  the 
lens,  haemorrhage  into  the  anterior  chamber,  vitreous  or 
retina,  rupture  of  the  retina  or  choroid,  opacity  of  the  lens, 
pigmentary  changes  in  the  retina,  some  optic  atrophy,  detach- 
ment of  the  iris;  svmpathetic  irritation  and  inflammation  may 
follow. 

(2)  Exposures. 

(a)  To  bright  light. 

Eclipse   blindness  is  an  affection  of  the  macular  region  of 

the  retina  from  exposure  to  direct  sunlight.     The  changes 

are  probably  of  a  chemical   nature  brought  about  by  the 

ultra-violet  rays. 
Night  blindness  occurs  in  badh'  nourished  individuals  from 

exposure    to    indirect    sunlight    unaccompanied    by    any 

ophthalmic    changes.       The    condition    may    be    due    to 

failure  of  the  visual  purple  which  has  been  bleached  by 

the  bright  light.        Bright  light  reflected  from  the  snow 

will  also  cause  blindness. 
Erythropsia.     A  red  vision  due  to  bright  reflected  light.     It 

usually  occurs  in  persons  whose  lenses  have  been  removed. 

The  cause  is  uncertain,  it  is  possibly  due  to  hyperaemia 

of  the  retina. 
Cataract.     This  is  common   where  there   is  much   reflected 

light.     Arc  lights  will  cause  it.     The  condition  is  common 

in  glass-blowers. 
Sponge-fisher's    Asthenopsia.      This     is    an     hyperaesthetic 

condition  caused  by  the  scintillation  of  sunlight  upon  the 

water. 


iio  />'y^y:.i.W:A   i>j-   J  nil  iiVE 

Li^htniu^,   by  means  of  its  ultia-violt'i   rnvs.   may   result   in 
blindness  tliroii^h  :  — 

1  lie  heat   rays  produtin^^  burns. 
Hlectrolytic  action. 

Concussion  causing  a  disturbance  of  the  circulation. 
.Sunlight   is  al.so  said  to  cau.se  a  spring  catarrh  which  dis- 
appears in  autumn  and  winter. 
(6)  Wind  and   Dust.      These  will  cause:  — 

Pitiguccuhi,   a   yellow    thickening  of  the  outer  conjunctiva: 

opposite  to  the  palpebral   fissure. 
Ptervf^ium,   an   extension    of  a   triangular   va.scular   fold   of 

conjunctiva  spreading  lo  the  cornea. 
Ophthalmic  irritation  and  microbic  infection. 

(3)  Habits.  &c. 

Xerosis  among  debilitated  children  is  very  common,  esf)ecially 
in  the  Mast,  where  famine,  cholera  and  dysentery  are  pre- 
valent. 

Keratomuhichi,  an  ulci  rative  condition,  may  ensue  from  the 
same  cause. 

Cataract  in  India  is  chiefly  senile,  although  diabetes  is  common 
amongst  vegetarians. 

I'lonorrhaeal  conjunctivitis  is  common  as  a  result  of  unclean 
habits.  Inflammatory  conditions  arise  as  a  result  of  pilgrims 
bathing  in  infected  water. 

Toxic  amblyopia  is  caused  by  excessive  smoking  and  drinking, 
as  also  is  misty  vision.  Tiiere  is  a  central  colour  scotoma 
for  red  and  green  especially.  There  must  be  immediate 
cessation  of  the  causiitive  factor. 

(4)  Insects  and  Parasites. 
(a)  Insects. 

.Stings  cause  ix'dema  of  the  lids  and  conjunctive'^. 
Irritating   secretions   are    troublesome,   e.g.,    the   eye-fly    of 

India,  the  great-ant  of  Senegal,  &c. 
Pediculis  pubis  may  occur  on  the  eyelaslies. 
Sarcopleri  invade  the  free  edges  of  the  eyelids  by  burrowing 

beneath  the  skin.     It  is  not  uncommon  in  .San  Domingo. 
Larva."   may    be   deposited    in   or  about    the   eye   by   Musca 

vomitoria,    Dermatobia    noxalis   and   cyaniventris,    Sarco- 

phaga   magnitica. 
Hairs  or  horns  mav  find  a  resting  place  here.     Ophthalmia 

nodosi  is  due  to  the  liairs  of  liombyx  rubi. 
Infective  discharge  is   not  uncommonly   carried  to  the  eye 

as  by  .Musca  domestica. 
Irritating  pollen  may  cause  vesicular  eruption. 


LOCAL   DISEASES    OP   THE   EVE  511 

(/*)  Animal  parasites. 

Filaria  loa  may  cause  trouble  beneath  the  skin  of  the  eyelids 

and  conjunctiva  as  in  West  Africa. 
Filaria  oculi  humani  may  insert  itself  in  tiie  eyeball. 
Cysts  containing  Paragonimus  westermanii  have  occurred  in 

the  eyelids  and  orbit. 
Dermanyssus  gallina?  in  the  cornea. 
Demodex  folliculorum  in  the  Meibomian  glands. 
Cysticercus    cellulos^e    in    the    choroid,    vitreous,    retina   or 

ciliary  region. 
Amongst  other  parasites  that  have  been  'found  troublesome 

are  :      Agamodistomum     ophthalmobium,      Monastomum 

lentis,  Sparganum  rhansoni  and  Filaria  palpebralis. 

(c)  Fungi. 

These  play  an  important  part  in  local  eye  diseases  as  the 
following  list  will  show. 

Ocular  blastomycosis  is  caused  by  Cryptoccccus  dermatitis 
and  various  Saccharomyces.  Papules,  pustules  and  an 
ulcerative  warty  condition  of  the  eyelids  is  produced. 

Ocular  tinea  is  caused  by  the  Microsporon  lansomum  and 
the  Trichophyton  tonsurans.  There  are  crusts  and 
pustules  about   the   cilia. 

Ocular  aspergillosis  is  caused  by  Aspergillus  fumigatus. 
There  are  pain,  abscess  and  ulcer  formation. 

Ocular  nocardiasis  is  caused  by  Nocardia  bovis,  N.  israeli, 
N.  foersteri,  N.  dassonvillei,  all  which  produce  actinomy- 
cotic conjunctivitis,  corneal  ulcers,  miliary  metastases  in 
the  choroid  and  lachrymal  concretions. 

Ocular  moniliasis  by  Monilia  albicans,  the  organism  of 
"  thrush  "  and  perhaps  of  sprue. 

Ocular  genosporosis  by  Genospora  graphii  (rare). 

Ocular  sporotrichosis  by  Sporotrichum  beurmanni  infecting 
the  eyelids,  conjunctivae,  lachrymal  sac  and  iris. 

(5)  Local  eye  conditions  not  previously  dealt  with. 

Congenital  defects  are  not  uncommon,  such  as  anophthalmos, 
microphthalmos,  coloboma,  albinism  and  errors  of  refraction. 
Conjunctivitis. 
(a)  Conjunctivitis  catarrhalis. 

Acute  :  this  is  caused  by  the  Koch-Weeks  bacillus  and  is 
nearly  always  severe,  also  by  the  IMorax-Axenfeld  bacillus 
which  causes  a  mild  type,  also  by  the  pneumococcus  and 
staphylococcus  less  com.monl\-.  This  latter  may  occur  in 
epidemics. 


112 


DISEASES    OE    THE    EYE 


Chronic,  caused  l)y  wind,  dust,  eye-strain,  alcoliolic  ex- 
cesses, foreign  bodies  and  ilic  Morax-Axenfeld  bacillus, 

P'ollicular,  this  variety  occurs  in  epidemics.  Ii  may  be 
bacterial  and  acute  or  non-bacterial  and  chronic. 

There  are  small  round  jKile  pfranulcs  the  size  of  a  pin's  head 
found  chiefly  about  the  inferior  fornix.  In  trachoma  the 
g"ranul('s  are  larijfcr  and  in  the  superior  fornix. 

(6)  Gonorrhwal  Conjunctivilis. 

This  is  met  with  in  babies  and  adults.  A  streptococcus  may 
also  cause  a  similar  condition  in  ciiildrcn. 


Gonococcus.      x  950. 
(By  Hansel!  and  Sweet.) 


Pneumococcus.      x  950. 
(By   llansell  and  Sweet.) 


bacillus  laciinatis  Mora\-.\\enfeld.    x  950. 
(I'.y  Hiinscll  and  Sweet.) 


Kocli-Woeks  bacillus.       x  950. 
(liy  llansell  and  Sweet.) 


(c)   (iraiiuhir   Conjunctii'itis  or    Truchowa. 

Seventy  per  cent,  of  the  children  in  Monq^-kong  are  infected. 

It   is  al.so  common  in   India,  Japan,  South  America,   North 

.\frica,  especially  in  F.u^ypt,  South  .Africa  and  other  parts. 


LOCAL   DLSEASES    OF   THE   EYE  513 

ETIOLOGY. 

IVachoma  is  found  among-  the  poorer  classes.  Certain  races  seem 
predisposed  to  it,  as  the  Jews  from  Russia,  the  Germans,  Austrians 
and  the  poorer  population  of  the  Balkan  States. 

Some  affirm  that  the  causative  organism  is  a  fungus,  Microsporon 
trachomatosum,  others  affirm  that  it  arises  from  chronic  urethritis  and 
vaginitis,  the  organisms  being  carried  by  towels,  hands,  &c.,  to  the 
eyes.  Cell  inclusions  of  a  chlamyzoan  nature  have  been  found  in  these 
discharges  and  also  in  the  trachomatous  nodules.  The  disease  is 
important  because  of  its  disastrous  complications  and  sequelas. 

DEFINITION. 

An  acute  or  chronic  inflammation  of  long  duration,  accompanied 
by  hypertrophy  of  the  conjunctivae  and  the  formation  of  "  granules  " 
with  subsequent  cicatricial  changes. 

SYMPTOMATOLOGY. 

Photophobia,  lachrymation,  itching  and  burning  sensation,  pain, 
visual  disturbance,  swelling  of  the  eyelids,  narrowing  of  the  palpebral 
fissure,  drooping  of  the  upper  lid  from  weight,  swelling  and  stiffness; 
muco-purulent  discharge,  marked  in  recent,  scantv  in  chronic  cases. 
The  conjunctiva  of  the  larsus  and  fornix  is  reddened,  thickened  and 
uneven  on  account  of  the  hypertrophy  and  granules.  These  granules 
are  rounded  collections  of  lymph  corpuscles  in  a  connective  tissue 
reticulum.  Papillar}-,  granular  and  a  mixed  form  are  recognized. 
Cicatrical  changes  occur  Axhich  ma\'  cure  the  trachoma  but  which 
unfortunately  give  rise  to  the  sequelae.  The  disease  often  manifests 
intermissions  and  exacerbations.  Relapses  are  common  and  treatment 
is  often  discontinued  too  soon. 

COMPLICATIONS  AND  SEQUELAE. 

Pannus  is  common.  It  consists  of  a  newly-formed  vascular  tissue 
often  covering  the  upper  part  of  the  cornea,  the  vessels  springing  from 
the  conjunctival  vessels  at  the  limbus.  The  entire  cornea  mav  be 
covered.  The  condition  is  not  merely  due  to  mechanical  irritation  but 
also  to  changes  like  those  of  the  conjunctiva.  Iritis  and  corneal  ulcers 
may  be  present,  the  latter  having  opacities  interfering  with  the  vision. 

Corneal  opacities  when  chronic  leave  a  permanent  layer  of  con- 
nective tissue  causing  the  opacity. 

Cicatrization  leads  to  :  — 

Trichiasis  :    the  cilia  are  turned  backwards  and   mav  touch  the 
cornea. 

3^A 


SM  DISEASES    Of    THE    EYE 

nintropiun  which  is  more  pronounrod  in  tlic  upper  lid.  The 
distorted  ciha  may  cause  corneal  ulcer.  The  ed^e  of  the  lid 
is  turned  inwards. 

Kclropion  when  the  etl.i,n*  of  ihc  lid  is  everted  and  the  lower  lid 
is  usually  affecieti.  li  is  the  result  of  ihe  cicatrization  of  the 
conjunctiva  ami  the  hypertrophy  and  contraction  o'f  ihe 
orbicularis  muscle. 

Symblepharon  is  le.ss  common.  The  foi-nix  is  obliterated  and 
the  eve  movements  limited. 


^v 


r:^T^ 


X^fh8^i^e  M/II  , 


Trachoma   bodies   of    Prowazek-Greeff.      (Giemsa   stain.)     Courtesy   of 
Dr.  Brown  Pusey.     (From  "Webster's  Diagnostic  Methods.'') 


Staphyloma  is  rare,  and  when  present  is  of  the  cornea. 

Xerosis  is  a  dry  scaly  conlracteil  condition  of  the  conjunctiva  with 
changes  of  the  cornea  in  severe  cases  due  to  loss  of  the  secreting  powers 
of  the  conjunctivae 


TREATMENT. 

For  local  a|)plicaiion  use  copj)er  sulphate  pencil  once  daily  followed 
by  an  eye  wash  of  warm  boric  acid  and  iced  compresses.  This  can  be 
pursued  for  months. 

Silver  nitrate,  i  lo  2  per  cent,  solution  is  g(^)d  when  there  is  much 
discharge,  followed  by  .siiline  eye  washes. 


LOCAL   DISEASES    OF   THE   EYE 


515 


Glycerine  of  tannin,  5  to  25  per  cent.,  and  alum  stick  are  also  used. 
Carbon  dioxide  snow  applied  once  fornightly  is  good  but  it  requires 
cocaine  for  its  application. 
Surgical  remedies  are  :  — 

Expression,  perhaps  the  most  popular.  Use  Knapp's  roller 
forceps  for  squeezing  out  the  granulations.  Wash  after- 
wards with  mercury  bichloride.  General  anaesthesia  is 
usually  required. 


Native  Chinese  operation  for  lower-lid  entropion,  pinching  the  skin  between  two  small 
sticks.  In  this  case  the  compression  was  not  complete  and  two  curious  tumours 
resulted.     (By  Jeffreys.) 


Grattage,  which  consists  of  scrubbing  the  granulations  with  a 
stiff  tooth  brush,  followed  by  an  eye  wash  of  mercury  bi- 
chloride with  or  without  previous  scarification. 

Excision,  to  remove  the  conjunctival  fold  containing  the 
granules.     The  conjunctiva  is  often  injured  in  this  process. 

Curetting  is  popular  with  some  surgeons. 


5i6  DISEASES    01-    J  HI:    liYE 

LUrtroly.sis,  X-rays,  racliuin  and  tin-  j^Mlvaiin-cautci y  an-  iist^ul 

in  the  hands  of  skilled  operators. 
Whatever  the  treatment   it  must   he  coniiniitd   until  every  trace 

of  hvpertrophy  has  disappeared. 
Prophvlaxis   is    most    im|xjrtani    and    necessiiry    warning    with 

appropriate  advice  must  be  given  to  those  concerned. 
An  epidemic  of  trachoma  is  a  .serious  matter. 

(d)  Spriufi  Catarrh  or  Conjuuclivitis  ccstivalis. 

This  varietv,  which  resembles  trachoma,  occurs  in  tiic  spring- 
and  summer.  Tiu-  conjunctiva'  may  be  covered  with 
flattened  jiapilla'  of  a  bluisii  tinge. 

The  intermittent  and  recurrent  nature  of  the  disease  with 
the  reappearance  of  the  granules  will  difi^erenliate  this  from 
trachoma.  The  letiology  is  unknown.  The  condition 
mav  last  for  years  and  then  dear  up.  There  is  no  known 
cure  and  the  treatment  is  symptomatic. 

(e)  Epithcliosis  desqiiamaliva  or  Samoan   eye  disease. 

There  is  a  milkv  secretion  from  trachoma-like  bodies.  Some 
of  the.se  are  intracellular  and  form  a  cell  inclusion  of  small 
granules  or  "  elementary  bodies  "  which  stain  violet-red 
with  Giemsa's  stain.  The  extracellular  bodies  are  tiiose 
that  are  more  mature.  True  granules  do  not  develop. 
The  conjunctiva  atrophies.  The  disease  is  common  in 
Samoa  as  is  indicated  by  its  name.  The  suggested  para- 
site is  a  chlamydozoon,  Lycozoon  atrophicans. 
(/)  Phlyctenular  conjunclivitis  and  keratitis. 

This  is  fairly  common  in  China.  There  are  small  reddened 
projections  (phlyctenuki?)  consisting  of  accumulated 
hniphoid  cells  which  .soften  at  their  apices  forming  a 
small  ulcer.  They  nia\-  occur  on  the  conjunctiva?  or  the 
cornea.  Sometimes  they  appear  in  crops,  each  phlyctenule 
from  two  days  to  two  weeks. 

Relapses  are  common.  This  di.sease  is  found  in  chiklren 
of  .so-called  scrofulous  diathesis  and  seems  to  be  caused  by 
some  constitutional  or  dietetic  error.  For  treatment,  dust 
with  calomel  daily  or  use  yellow  oxide  of  mercury,  i  to  2 
per  cent. 

Corneal  ulcers  are  not  uncommon. 

Treat  with  the  actual  cautery  and  atropine. 

( )ne  p<'r  cent,  xeroform  ointment,  mois;  warm  compresses, 
hydrogen  peroxide,  formalin  1   in  40.  \-c. 

Cocaine  is  nece.s.sary  for  the  actual  cautery. 

Perforations  require  iridectomy. 


M 


>>  >> 


CATARACT  517 

CATARACT. 

This  is  an  opacity  of  the  lens  or  its  capsule. 

NOMENCLATURE. 

If  the  opacity  commences  about  the  centre  of  the  lens  it  is  a  nuclear 
cataract,  if  about  the  periphery  il  is  a  cortical  cataract.  The  former 
tend  to  develop  in  old  age,  the  latter  during  middle  life. 

The  hard  variety  are  senile,  common  after  the  forty-fifth  year  and 
can  be  extracted,  but  the  soft  may  occur  from  childbirth  to  the  thirtieth 
year  and  require  needling,  &c.  All  cataracts  occurring  under  the 
thirtieth  year  are  soft. 

Cataracts    are    primary    when     independent    of    any    other    ocular 
condition. 
,,  ,,     secondary     when     other     ocular     disturbances     are 

present. 

lenticular  when  in  the  substance  of  the  lens. 
capsular  when  affecting  the  capsule. 
capsulo-lenticular  when  involving  both. 
,,  ,,     stationary  when  they  remain  incomplete. 

,,  ,,     progressive  when  they  spread  and  tend  to  affect  the 

whole  lens. 
,,  ,,     congenital  when  they  are  due  to  faulty  intrauterine 

development  or  inflammation. 

These    include    the    anterior    and    posterior    polar, 
lamellar  and  sometimes  the  complete  cataract. 
,,  ,,     traumatic  when  the  capsule  is  pierced  or  ruptured  by 

a  foreign  body  or  bv  a  simple  concussion  allowing 
the  lens  to  absorb  the  aqueous  humour. 
We  shall  follow  a  classification  of  May  and  Worth  and  deal  with 
each  seriatim. 

A.  Stationary  Cataracts. 
(i)  Anterior  polar. 

(2)  Posterior  polar. 

(3)  Lamellar. 

(4)  Uncommon  forms. 

B.  Progressive  Cataracts. 

(i)  Senile,  cortical  and  nuclear. 

(2)  Congenital,  juvenile. 

(3)  Traumatic. 

(4)  Catarrhal  eye  complications. 

(5)  After  cataract. 


5i8  n/sf-ASFS  01'  rur.  rye 

A.   (1)   Anterior  Polar  or  Pyramidal  Cataract. 

ii  is  an  opacity  situaU-d  ai  llic  anterior  pole  of  the  lens 
beneath  ihe  capsule.     It  may  be  conp^enital  or  acquired. 

In  the  ac(|uired  form,  a  corneal  ulcer  perf<jr'ates  the  cornea, 
irritates  the  lens,  producin},^  a  proliferation  of  the  sub- 
capsular epithelium.  Interference  with  vision  is  slight. 
The  treatment  is  usually  nil. 

The  anterior  chamber  is  restored  later. 

A.   (2)   Posterior  Polar  Cataract. 

Conm'u'lliil,  I  his  is  central  and  due  to  ilic  remains  of  the 
hvaloid  arterv  which  ajijiears  as  a  black  dot  upon  the  red 
fundus  reflex. 

Xo  treatment   is   required. 

Acquired,  this  is  cortical  and  stellate  in  shape.  It  develops 
in  connection  with  high  myopia,  choroiditis,  diseases  of 
the  vitreous  and  retinitis  |>igmentosa.  These  remain 
stationary  for  years  and  may  become  complete.  Vision 
is  impaired  and  treatment  useless.  Deal  with  the 
accom pa  n y  i  n  g  condition. 
A.   (3)   Lamellar  or  Zonular  Cataract. 

These  are  congenital  or  infantile.  They  are  most  commonly 
seen  in  children  and  usually  alTect  b<jth  eyes,  being 
associated  with  rickets,  a  general  disorder. 

It  appears  as  a  grey  disc-like  opacity  surrounded  or  being 
surrounded  by  a  clear  transparent  portion  of  the  pupil. 
It  is  most  dense  at  the  margin  of  the  disc.  The  visual 
interference  may  be  slight  or  severe. 

Iridectomy  can  always  be  done  and  the  vision  improved. 
riif    portion    chosen    for    iridectomy   should    be   downwards 
and  inwards.     In  ihc  young  discission  can  be  practised,  in 
elder  people  extraction  of  th(»  lens  is  done. 

A.  (4)    Unconinion  Forms. 

.All  congenital  are  .somewhat  uncommon. 
Interference  with  the  \ision  is  slight.      There  mav  be:  — 
a  central  while  opacity   in  the  lens; 
a  fusijorm,    spindle-shaped    opacity    stretching   from    the 

anterior  to  the  posterior  pole, 
a  pituctalc   cataract    having    numerous    small    white    dots 
distributed  throughout  the  lens. 

B.  (1)   Senile  Cataract. 

This  is  the  most  common  form  of  cataract. 

Ik)th  eyes  are  commonly  affected,  one  following  the  otlier. 


CATARACT 


519 


'Jlie  nucleus  remains  transparent,  months  or  \-ears  mav  be 
required  for  tlie  ripening  to  be  completed,  it  may  become 
stationary  at  any  stage. 

1.  The  Incipient  Stage. 

There  are  streaks  of  opacity  from  the  cortex  to  the  centre 
of  the  lens  where  the  streaks  become  narrower.  Less 
rarely  there  are  dots  or  a  general  haziness. 

2.  The  Swelling  Stage. 

The  lens  absorbs  fluid,  swells,  pushes  the  iris  forward 
and  so  reduces  the  depth  of  the  anterior  chamber.  The 
cataract  becomes  stellate  in  appearance. 

3.  The  Mature  Stage. 

The  lens  loses  most  of  its  fluid,  shrinks,  is  completely 
opaque,  the  anterior  chamber  is  normal  in  depth,  the 
entire  lens  may  be  a  hard  ''  black  cataract."  It  is 
now  easily  separable  from  the  capsule  and  is  "ripe," 
ready  for  removal  by  extraction. 

4.  The  Hypercemic  Stage. 

The  mature  stage  continues  or  irregular  spots  may  be 
apparent.  The  lens  may  lose  more  fluid  and  mav 
become  a  "shrunken"  cataract,  or  soft  and  milkv, 
and  the  nucleus  sinks  into  the  fluid  which  then  equals 
"  Morgagnian  "  cataract.  Lime  salts  (chalky  cataract) 
or  cholesterin  may  be  deposited. 

The  anterior  capsule  may  become  thickened  and  opaque 
(capsulo-lenticular  cataract). 

TREATMENT. 

Extraction  is  the  only  means  available,  medicinal  treatment 
is  useless.  Atropine  may  temporarily  assist  vision  in 
some  cases. 

Removal  of  both  cataracts  at  the  same  time  should  never  be 
carried  out. 

Artificial  ripening  may  be  resorted  to  so  as  to  hasten  the 
process  by  incising  the  cornea,  allowing  the  aqueous 
humour  to  escape  and  the  cornea  to  fall  against  the  lens, 
but  such  procedure  is  not  free  from  risk. 

When  is  a  Senile  Cataract  ready  for  Operation  (?).    Tests, 
(i)  Examine  by  focal  illumination. 

If  the  opacity  comes  forward  to  the  iris,  so  that  the  latter  throws 
no  shadow  on  the  lens,  then  the  cataract  is  probablv  mature. 
(2)  Cover  one  eye  and  throw  a  strong  light  suddenly  upon  the  one 
to  be  tested;  the  pupil  should  then  contract. 

3Z 


j20  DISIiASES    or    Till-:    EYE 

{X)  TIr-  |)aii(.'nt  miisi  have  ^^n>d  perception  of  liglil ;  that  is  to  say, 

he  must  appreciate  the  covering  of  the  eye. 
(4)  His  peripheral  vision  should  be  good. 

The    jxjsition    of-  a     lighted    candle    when    placed     in     varying 
|)ositions  in  a  darU  r(M)m  should  be  appreciated  by  the  patient 
when  looking  straight  forward. 
H.Nlraciion    can    be    carried    out    with    or    without    iridectomy    as 
follows  :  — 

(i)  The   Corneal  Section. 

Cocaine  with  a  few  drops  of  adrenalin  are  necessary,  rarely 
general  ana'Sthesia.  Tlu'  patient  looks  downwards,  fixation 
forceps  are  applied,  the  (Iraefe  knife  enters  the  cornea,  with 
the  cutting  edge  upwards,  a  knife's  breadth  above  the  hori- 
zontal meridian,  and  the  corneal  flap  completed.  The  knife 
must  not  be  twisted,  the  aqueous  humour  must  not  escape, 
and  the  iris  must  not  be  cut. 

(2)  The  Iridectomy. 

The  conjunctival  ilap  is  turned  forwards  on  to  the  cornea, 
curved  iris  forceps  are  inserted  and  grasp  the  upper  margin 
of  the  pujDil,  which  is  gently  drawn  out  and  a  small  portion 
removed  with  scissors. 

(3)  Opening  of  the  Capsule. 

The  cystotome  is  inlrtxiuced  flatwise  into  the  anterior  chamber, 
its  point  turned  towards  the  capsule,  which  is  gently  cut. 
The  incision  may  be  T-shaped,  A-shaped,  or  +-shaped. 

(4)  Delivery  of  the  Cataract. 

Gentle  pressure  is  exercised  upon  the  lower  part  of  the  cornea 
towards  the  centre  of  the  globe  w  ith  the  back  of  the  spoon  ; 
the  section  opens  and  the  lens  presents. 

(5)  The   ]]'ound  Toilet. 

Stroke  the  cornea  upwards  to  remove  any  cortical  remnants  and 
blood-clots.     The  edges  of  the  section  must  be  clear. 

The  lids  must  not  touch  the  wound.  The  coloboma  is  flattened 
out  with  a  spatula;  adjust  the  flap,  insert  a  drop  of  atropine 
and  close  the  lids. 

(6)  The  Dressings,  ^'c. 

Cover  with  gauze,  both  eyes,  and  add  cotton  wool  soaked  in 
antiseptic  and  fix  with  a  binocular  bandage. 

The  patient  must  remain  upon  his  back,  quiet,  anodynes  are 
best  given,  straining  is  to  be  avoided,  the  wound  examined 
and  atropine  instilled  daily,  the  iris  excised  if  prolapsed; 
liberate  the  unoperated  eye  on  the  fifth  day  when  the  patient 
may  sit  uj).     In  two  weeks  smoked  glasses  are  worn. 


CATARACT  521 

Later,   in  four  weeks,  the  hypermetropia  is  about  10  D.,  with 
some  astigmatism   of  2   to  3  d.   due  to  the  incision.     Give 
therefore  a   convex   spherical   lens  of    10   d.   with  a   convex 
cylinder  of  2  to  3  d,  for  distant  vision,   wi'th  an  additional 
convex  sphere  of  3  to  4  d,  for  reading. 
Previous  errors  of  refraction  will  modify  this  correcting  lens. 
Some  operators  omit  the  iridectomy,  thus  avoiding  prolapse  of  the 
iris,  but  the  capsule  is  more  liable  to  be  left  in  the  wound. 

Soft  and  traumatic  cataracts  are  evacuated  by  tearing  the  capsule 
with  a  c}'stotome. 

In  India  many  surgeons  remove  the  cataract  in  its  capsule.  In 
such  cases  the  suspensory  ligament  is  ruptured,  capsulotomy  omitted, 
and  the  lens  expressed  bv  corneal  pressure  with  a  squint  hook.  The 
grave  risk  of  the  lo5S  of  vitreous  is  the  chief  danger. 

Complications  of  extraction  include  :  — 

Loss  of  vitreous,  lens  dislocation,  wounding  prolapse  of  the  iris, 
incomplete  evacuation,  intraocular  haemorrhage,  striated  kera- 
titis, glaucoma,  iritis,  iridocyclitis,  cyclitis,  suppuration  and 
panophthalmitis. 

B.   (2)   Congenital  and  Juvenile  Complete  Cataract. 

These  are  uncommon;  always  soft;  bluish  white  with  a 
pearly  lustre  in  one  or  both  eyes.  The  eye  may  be  other- 
wise normal,  or  there  may  be  other  eye  complications. 

There  is  often  a  history  of  heredity,  convulsions  and  other 
mal-intrauterine  developments. 

Treatment  is  that  of  discission  (needling). 

This  should  be  done  early,  and  needs  to  be  repeated  a 
number  of  times.  If  the  patient  is  young  give  a  general 
anaesthetic,  if  older  a  local  anaesthetic  is  sufficient. 

Dilate  the  pupil,  introduce  the  speculum,  steady  the  eye  with 
fixation  forceps,  divide  the  cornea  and  the  lens  capsule, 
making  two  superficial  cross  cuts,  break  up  the  lens 
matter  by  rotating  a  needle  so  that  the  lens  matter  will  be 
absorbed. 

Repeat  this  after  several  weeks.  The  discission  must  be 
deeper  each  time,  and  finally  include  the  posterior  lens 
capsule. 

Three  operations  are  usually  required. 

Keep  the  pupil  dilated  with  atropine. 
B.   (3)   Traumatic  Cataract. 

This  is  the  result  of  a  wound  involving  the  lens  capsule,  or 
more   rarely  after  concussion.     Swelling  and   cloudiness 


522  DISEASES    OF   THE    EVE 

of  the  pupil  last  for  srvrral  days  when  ihr  lens  becomes 
absorbed. 
Often  the  cure  is  spontaneous,  but  part  may  remain  behind, 
become  opacjue,  and  recjuire  operation.  Iritis  and 
j^laucoma  are  not  uncommon.  Treat  on  /general  Unes 
indicated. 

B.    (4)   Cataracts  of  Eye  Complications. 

1  lie  t(jilo\\  in^  condiiii-ns  may  lead  lo  cataracts  :  — 
Iridocyclitis,  choroiditis,  severe  corneal  ulcer,  glaucoma, 

retinitis  pigment<jsii,  and  retinal  detachment. 
Such  often   begin    in   the  posterior  part  of  the  lens  and 
tend  to  degenerate.     Treat  the  causative  factors. 

B.   (5)   After  Cataract. 

This  is  due  to  the  opaque  remains  of  the  lens  capsule,  pro- 
liferation of  subscapular  epithelium  or  new  connective 
tissue  after  ordinary  cataract  operation. 

Practice  discission  five  weeks  after  extraction,  but  wiili  a 
very  sharp  knife  and  not  an  ordinary  discission  needle. 

An  iridocystectomy  may  be  necessary. 

ocn.AK  .\i.\\ii-i:sr.\Ti()Xs  of  c.i-m-ral  diseases. 

These  will  be  dealt  witii  i^riefly  seriatim. 

Pernicious  anaemia  causes  iia?morrhages  and  retinitis. 

I  hemophilia  may  result  in  profuse  haemorrhage  after  injury. 

Leukaemia  causes  retinal  hemorrhages  and  a  distinct  retinitis. 

Purpura  causes  subconjunctival  iKumorrhage,  retinal  haemorrhage. 

Endocarditis  causes  embolism  of  the  central  artery. 

Aortic  aneurysm  causes  mydriasis  and  exophthalmos  or  miosis,  and 

Arteriosclerosis  results  in  marlced  changes  in  the  exophthalmos 
fundus. 

Oral  sepsis  to  a  c|uiet  cyclilis,  iritis  and  keratitis. 

Dyspepsia  to  iridocyclitis,  choroiditis  and  retinitis. 

Rectal  tenesmus  to  subconjunctival,  retinal  and  vitreous  ha.Mnor- 
rhage. 

Acromegaly  to  bitemporal  hemianopsia,  reduced  acuteness  of  vision, 
optic  neuritis,  optic  atrophv,  .some  ocular  parahsis.  exophthalmos, 
epiphora  and  eye  pain. 

Exophthalmic  goitre  to  exophthalmos  and  corneal  ulcers,  ocular 
j>aresis. 

Cerebrospinal  meningitis  to  conjunctival  (vdema,  ocular  paresis, 
strabismus,  ptosis,  nystagmus,  keratitis,  optic  neuritis  and  atrophy. 

Dij^htheria  to  paralysis  of  extrinsic  muscles  and  optic  neuritis. 


OCULAR    MANIFESTATIONS    OF    OENERAL   DISEASES    523 

Erysipelas  to  orbital  cellulitis,  &c. 

Influenza  :   asthenopia,  corneal  ulcer,  paresis  of  ocular  muscles. 

Pneumonia:   corneal  herpes  and  ulceration. 

Septicaemia  and  pyaemia  :  retinal  haemorrhage,  emboli,  purulent 
choroiditis. 

Syphilis  :  iritis  (25  per  cent,  of  all  iritis  cases),  choroiditis,  chorio- 
retinitis, optic  neuritis  and  atrophy,  gummata  of  the  iris,  ciliary  body 
and  periosteum,  interstitial  keratitis,  paralysis  and  paresis. 

Tuberculosis :  deposits  in  the  iris,  choroid,  sclera,  conjunctivaj 
and  lids. 

Variola  :  pustules  of  the  lids,  conjunctivas,  keratitis  and  ulceration, 
complete  destruction  of  the  globe,  ectropion,  entropion  and  trichiasis. 

Nephritis  :   oedema,  albuminuric  retinitis  and  amblyopia. 

Diabetes  :  cataract,  retinal  haemorrhage,  retinitis,  optic  neuritis, 
retrobulbar  neuritis,  pareses,  paralyses  and  myopia. 

Gout  :  episcleritis  and  scleritis,  dry  catarrh,  marginal  ulcer  of  the 
cornea,  glaucoma  and  ha?morrhagic  retinitis. 

Rickets  :  congenital  zonular  cataract,  interstitial  keratitis,  phlyc- 
tenular keratoconjunctivitis. 

Scurvy  :  haemorrhages  of  any  part,  temporary  night  blindness, 
apoplexv  and  retinal  haemorrhage. 

Friedreich's  disease  :    nystagmus,  ocular  paralyses,  optic  neuritis. 

G.P.I.  :  irregular  pupils,  miosis,  mydriasis,  Argyll-Robertson 
pupil,  impaired  or  loss  of  accommodation,  optic  atrophy,  paralysis  of 
the  third,  fourth  and  sixth  nerves  leading  to  diplopia,  strabismus  and 
ptosis. 

Coma  :  choked  disc,  mydriasis  (organic  brain  disease),  miosis, 
inequality  of  pupils,  conjugate  deviation  (cerebral  haemorrhage), 
albuminuric  retinitis  (uraemia),  dilated  pupils  and  pareses  (alcohol), 
extreme  miosis  (opium). 

Epilepsy  :  transient  flashes  of  light,  coloured  sensations,  hemi- 
anopia,  complete  loss  of  vision,  muscular  spasm,  conjugate  deviation, 
distension  after  narrowing  of  the  retinal  arteries. 

Poisonings  :  retrobulbar  neuritis,  optic  atrophy  (tobacco  and 
iodoform,  lead,  arsenic,  e.g.,  atoxyl  in  trypanosomiasis,  carbon- 
bisulphide  and  nitrobenzol). 

Heat-stroke  :   amblyopia  and  optic  neuritis. 

Typhoid  fever :  convergence,  impaired  accommodation  and 
mydriasis. 

Relapsing  fever  :    iridocyclitis  and  iritis. 

Cholera  :  focal  necrosis  of  cornea  and  conjunctiva  with  ulceration, 
dry  catarrh,  enophthalmos  from  loss  of  fluid,  subconjunctival 
haemorrhage. 


524  I)  IS  RASES    OF   THE   EYE 

Dysentery  :   keratitis,  iritis,  iridocyclitis. 

Beri-beri  :  irdenia  of  lids,  lymphatic  spaces  in  opiic  nerve  and 
retina  distended,  defective  central  vision,  loss  of  central  colour  vision, 
axial  retrobulbar  retinitis,  spasm  and  paralysis  of  ocular  muscles. 

Kala-azar  :    retinal  luemorrhag^es  with  deposits  of  pigment  emboli. 

Snake  bite  :    iridocyclitis,   intraocular  luemorrhages. 

Oriental  sore  :  cicatricial  contraction,  ectropion,  epiphora,  spasm  of 
the  orbicularis. 

Yellow  fever  :   amblyopia,   hyjx'raMiiia  of  conjunctiva?. 

Trypanosomiasis  :  iritis,  keratitis  and  retinal  changes  in  untreated 
cases;  cataract  and  optic  atrophy  in  treated  cases. 

Plague  :  photophobia,  lachrymation,  conjunctivitis,  deepened 
anterior  chamber,  punctate  keratitis,  iritis,  contracted  pupil,  serous 
exudate,  later  plastic,  posterior  synechia,  increased  tension  of  eyeball, 
later  diminished  tension,  shallow  anterior  chamber,  vitreous  exudates, 
retinal  haemorrhages,  optic  neuritis,  optic  atrophy  and  panophthalmitis 
as  in  order  given. 

Leprosy  :  eyelashes  lost  early,  frontalis  muscle  paralysed,  nodular 
lepromata  and  ulceration  of  eyelids  with  destruction  later,  conjunctivitis 
leading  to  lagopthalmitis,  ectropion,  xerophthalmia,  infiltrated  epi- 
sclera,  whitish  grey  masses  spreading  round  cornea,  keratitis  punctata, 
leprosa,  anterior  and  posterior  uveitis,  nodules  in  ciliary  bodv  or  in 
spaces  of  Fonlana  causing  iridocyclitis  and  chronic  glaucoma. 

Ihe  optic  nerve,  retina,  lens  and  vitreous  humour  are  rarelv 
attacked.  .\  plastic  exudate  may  cause  posterior  svnechia,  i.e., 
adhesions  between  the  iris  and  lens  and  cau.se  occlusion  of  the  pupil 
and  consequent  blindness.  This  may  be  broken  down  in  earlv  cases 
by  an  effective  mydriatic,  pyelitis  causes  impaired  accommodation 
and  diminished  vision,  llceration  and  ])erforation  of  ihe  anterior 
chamber  are  not  uncommon  in  bad  cases.  X'ision  will  be  affected  bv 
the  .scar  if  in  the  pupillary  area. 

Hypopyon  is  not  an  uncommon  sequel,  i.e.,  pus,  llbrin  and  leuco- 
cytes with  pus  organisms  in  the  anterior  chamber.  In  cases  of  per- 
foration the  pyogenic  organisms  enter  the  eyeball  and  cause  total 
destruction  by  panophthalmitis. 

See  article  on  Leprosy. 

Malaria  :  eye  troubles  are  due  to  circulatory  disturbances  more  than 
to  inflammatory  conditions.  There  are  conjunctival  congestion,  photo- 
phobia and  lachrymation. 

Keratitis  dendritica,  a  herpes  cornea  zoster,  giving  rise  sometimes 
t(.  ulcers,  branch-shaped  with  knobs  on  them;  nine  out  of  ten  are 
Of  malarial  origin. 

Keratitis  profunda,    a   central    infiltration   of    the   cornea    which   is 


OCULAR  MANIFESTATIONS  OP  GENERAL  DISEASES     525 

brought  on  by  a  chronic  malarial  cachexia.  These  are  opaque  greyish 
dots. 

It  abates  in  from  four  to  eight  weeks. 

Vitreous  opacities  are  due  to  hjemorrhages  and  serous  effusion. 

Amaurosis  is  due  to  atrophy  of  the  optic  nerve. 

In  retinochoroiditis  the  papillae  are  obscured  and  the  retina  hazy. 
The  condition  is  due  to  the  parasites  in  the  vessels.  A  pigmented 
retina  is  left.  If  there  is  embolism  of  the  central  artery,  less  rare,  there 
is  sudden  loss  of  vision.  Optic  neuritis  and  oedema  may  be  caused 
by  the  blockage. 

Paralysis  of  the  accommodation  is  not  uncommon  in  malarial  con- 
ditions, but  secondary  iritis  is  rare. 

Supraorbital  and  ciliary  neuralgia  are  common. 

Amblyopia  is  less  frequent  and  may  be  caused  by  the  disease  or 
the  treatment  of  it,  i.e.,  malaria  or  quinine.  The  points  of  differen- 
tiation are  set  forth  in  the  following  table  :  — 


QUININE  AND  MALARIAL  AMBLYOPIA.     (After  Manson.j 


QUININE 
History — 

Quinine  must  have  been  taken  in  large 
doses,  not  less  than  thirty  grains. 

Onset — 

Sudden,  accompanied  by  deafness  ;  both 
eyes  are  affected 


Pupils 

Widely  dilated,  and  whilst  loss  of  vision 
continues  they  do  not  react  to  light 

Vision — 

Completely  lost  for  a  time 

Ophthalmoscopic  appearances — 

A  white  haze  over  fundus;     cherry-red 

spot    at    macular;     optic    disc    pale; 

retinal  vessels  markedly  constricted 

Termination — 

Usually  some  permanent  defect  in  the 
field  of  vision  or  in  colour  vision. 
Central  vision  recovers  first  ;  optic 
disc  is  unusually  white,  and  retinal 
vessels  small 

Treatment — 

Stop  quinine.  Amyl  nitrite  has  been 
recommended  to  induce  dilatation  of 
retinal  vessels 


MALARIA 


Quinine  may   have   been    taken  but    not 
necessarily  in  large  doses 


Not  usually  sudden,  but  it  may  be  so  if 
haemorrhage  has  occurred  in  the  macular 
region.  There  is  no  deafness,  and  both 
eyes  are  not  necessarily  affected 


React  to  light 


Never  completely  lost 


There  is  optic  neuritis  ;  optic  disc  is  of 
characteristic  greyish  -  red  colour;  le- 
tinal  haemorrhages  and  sometimes 
vitreous  opacities 

Some  cases  recover  completely;  in  others 
greater  or  less  permanent  defect  of 
vision  remains 


Give  quinine 


Quinine  causes  buzzing  in  the  ears  with  partial  or  complete  deaf- 
ness.    It  is  usually  temporary,  but  is  sometimes  permanent. 


526  DISEASES    OF   THE    EVE 

Persons  tuntemplaling  residence  in  malarial  tropics  should  undergo 
a  course  of  heavy  doses  of  tjuinine  in  luiroi>e  first. 

Persons  unable  to  take  the  dru^  well  should  not  be  permitted  to 
reside  in  the  tropics.  .Some  are  su.scep'.ible  to  the  drui;  in  small  doses, 
4  j^rains  producinj^-  unpleasant  symptoms. 

rill-:  rKi:.\  r.\ii:\  I  oi-  l■.^  i;  I)I.sj:.\si:.s. 

The  treatment  of  eye  diseases  is  local  and  j^^eneral,  but  we  are  only 
concerned  here  with  local  remedies,  which  will  be  dealt  with  on  general 
lines. 

(1)  Eye  Rest. 

Correct  errors  of  refraction  hv  suitable  lenses. 

Give  temporary  cessation  from  all  work  involving  eve-strain. 

Paralyse    the   accommodation    with    atropine,    homatropine   or 

hyoscyamine. 
Prescribe  protective  goggles  or  glasses,  eye-shades  or  bandages. 
Green  glasses  cut  out  the  ultra-violet  rays. 
Smoked       ,,  ,,         glare  of  light. 

Blue  ,.  ,,         heat  rays. 

(2)  Cleansing  and  Antiseptic  Solutions. 

All  solutions  must  be  warm. 

For  washing  the  eyeball  and  removing  discharges  use  :  — 

Sterilized  warm  water. 

.Saturated  .solution  of  boric  acid. 

Physiological   saline. 

Mercuric  chloride,   i  in   io,ooo  to  i   in  6,ooo  (one  grain  to  a 
pint),  formalin,    i   in  S,ooo  (one  minim  to  a  pint). 

Condy's  fluid  pure,   i   in  2,(kx)  (four  grains  to  a  pint). 

Carbolic  acid,  oin  per  cent. 

(3)  Stimulating  and  Astringent  Remedies. 
For  conjunctivitis:  — 

v„„     J     .11  .  ,        Give  two  drops  twice  daiy. 

AquiL-  deslill....         ...         ...     i   ounce      )  '^  ' 

R     Acidi  tannic! \  grain       ) 

Zinci  sulph \      „  ■•  „  „  „ 

Aquic deslill.  ...         ...         ...      i  ounce      ' 

K     Zinci  sulph ...     \  grain        | 

Sodii  biboras ...         ...         ...     3  grains      \  „  ,,  „ 

Aqu.x  destill.  i  ounce      ) 

9i     Acid,  tannic \  grain        j 

Zinci  sulph.    ...         ...         ...  \       ,,  I 

Aquic  camphora-      ...         ...  2  drachmsl  "  "  " 

.Aquai  destill.  ...         ...  6         „        / 


THE   TREATMENT    OP   EYE  DISEASES  527 

Silver  nitrate  can  be  used,  grain  ^  to  i  to  one  drachm.  This 
can  be  painted  on  the  lids  in  chronic  cases,  or  stronger,  grains 
I  to-  5  to-  one  drachm.     Wash  well  later  with  saline  solution. 

Keep  solution  in  a  stoppered  bottle  and  in  the  dark. 

Protargol  is  commonly  used,  10  to  25  per  cent. 

Copper  sulphate,  grains  }^  to  one  drachm.  It  is  usually  used  as 
a  pencil  in  trachoma. 

In  blepharitis,  conjunctival  interstitial  phlyctenular  keratitis 
use  yellow  oxide  of  mercury. 

For  persistent  ulcerative  blepharitis  use  :  — 

^     Ichthyol  10  grains 

Ung.  zinc.  ox.  2  drachms 

When  vasoconstrictors  are  required  for  the  absorption  of 
exudates  use  :  — 

^     Adrenalin  chloride  (i  :  rooo)     i   drachm 
Aquae  destill.  ad i  ounce 

^     Acid  boric 10  grains 

Suprarenal  (i  :  I'ooo)  ...  i  drachm 

Aquas  camph.  ...         ...  h  ounce 

Aquae  destill i       ,, 

Both  these  are  contra-indicated  in  corneal  ulcer. 

In  iritis,  keratitis,   glaucoma  and  corneal  ulcers  use  :  — 

Dionin,  a  derivative  of  morphine,  2  to  4  per  cent,  solution, 
two  drops  every  two  minutes  for  ten  drops.  It  relieves 
pain,  induces  local  anaesthesia,  is  a  vasodilator  and  a 
lymphagogue ;  it  is  a  counter-irritant  and  will  assist  in 
dilating  the  pupil  and  breaking  down  the  posterior 
synechia  caused  by  the  iritis  which  so  often  ends  in 
blindness.  This  drug  loses  its  effect  in  a  few  days,  so 
that  it  cannot  be  used  over  long  periods. 

(4)  Disinfectants  (so-called). 

These  are  for  restricted  use  only  and  required  to  be  followed 
by  excess  of  bland  solutions  to  remove  any  disinfectant  left 
behind. 
In  cases  of  purulent  conjunctivitis  and  corneal  ulcers  use  :  — 
Mercuric  chloride  i  :  5,000.     i  :  5,000  has  been  used  upon 

the  conjunctiva  after  trachoma. 
Chlorine  water  diluted  with  10  to  20  parts  of  water,  freshly 

made. 
Carbolic   acid,    3   per   cent,    and   pure    carbolic   to    infected 
corneal  ulcers.     Formalin,  i  :  1,000  to  i  :2,ooo.     i  :50o  to 
in'fected  ulcers. 
Tincture  of  iodine  for  infected  ulcers. 


528  DISEASHS    OJ-    THE   EYE 

Silver  nitrate,   i   to  j  per  rent. 

Protargol,    lo  to  25  per  cent.      Ii   has  a  feeble  action. 
The  actual   cautery   for  corneal    ulcers,   conical   cornea  and 
epithelioma   of   flie   lid. 

(5)  Mydriatics  and  Cyclople^ics. 

These  are  to  tlilaie  the  |)upil  and  paralyse  the  accommodation. 
Indications. 

To  dilate  the  jiupil  for  ophth.ilmic  examination. 

To  prevent  adhesion  in   iritis. 

I'or  central  ulcer  of  the  cornea. 

To  j)arahse  the  accoinmodation  in  order  to  estimate  the 
refraction. 

For  lamellar  and  nuclear  cataract. 

After  some  operations. 

In  certain  diseases  of  the  cornea  and  deeper  structures. 
Remedies. 

Atropine  in  solution  or  oininieiu,  i  j)er  cent.  The  effect 
lasts  for  a  week  or  more.  It  may  jirecipitate  an  attack  of 
glaucoma  in  a  predisposed  eye.  Some  patients  are  sus- 
ceptible to  its  use  and  show  toxic  symptoms.  Give 
morphine  as  an  antidote. 

Homatropine  hydrobromate  is  milder  and  almost  as  useful. 
The  effect  lasts  one  day  onl}  or  a  little  more.  Use  2  per 
cent.  soluiit)n,  one  drop  every  five  minutes  for  three  to 
four  doses. 

Kuphthalmin  for  examination  purjxjses.  5  to  10  per  cent, 
solution  ;  two  drops  onlx  .  The  effect  passes  off  in  a  few 
hours. 

Cocaine  hydrochlorate,  one  or  iwo  chops  of  a  4  per  cent, 
solution.  The  effect  passes  off  in  about  one  hour.  It 
will  usually  diminish  intraocular  tension. 

(6)  Myotics. 

To  contract  the  pupil  and  diminish  intraocular  tension. 
Useful  in  cflaucoma  and  f>eriplieral  corneal  ulcers, 
lilserine  salicylate  J  to  .]   per  cent.     It   may  cause  irritation. 
I'ilocarpine  nitrate  (muriate)  I  to  i  per  cent,  is  milder. 

l\     Eserine  sulph.  1-|  yrain 

Cocaine  miir.  ...         ...     2        ,, 

Ac|ii;e  destill.  ad       ...         ...     i  ounce 

(7)  Anaesthetics. 

General.     Chloroform  for  children;  ether  for  adults  if  possible. 
Cocaine  hydrochlorate,  2  to  4  per  cent.     It  a.ssists  the  action 
of  mydriatics  and  miotics,     (^ne  drop  is  sufficient  for  the 
removal  of  a  foreign  body. 


THE   TREATMENT    OF   EYE  DISEASES  529 

Holocain   hydrochlorate,    i    per  cent.     It  acts  quickly  and 

penetrates  deeply.     It  keeps  well. 
Eucaine  B.     This  is  best  used  hypodermically,  5  per  cent. 

solution  is  not  toxic. 
Novocain,   3   per  cent,   in   adrenalin   chloride,    i  :  1,000  for 

hypodermic  use. 

(8)  Various. 

Hot  compresses,  frequently  renewed  for  affections  of  the  cornea, 

iris  and  ciliary  body  are  useful. 
Cold  compresses  in   conjunctival   inflammation.     Lint   laid  on 

ice,  then  to  the  closed  eyelid,  frequently  renewed  is  soothing. 
Electricity.  Distorted  eyelashes  are  removed  by  electrolysis. 
Ionization  is  employed  for  corneal  ulcers,  interstitial  keratitis, 

trachoma,  rodent  ulcer,  &c.     It  is  painful  and  the  results  are 

not  very  encouraging. 
Blood  letting  by  leeches  in  cases  of  iritis  and  deeper  affections 

is  a  favourite  remedy  with  some.     Apply  two  to  four  to  the 

temple. 
Massage    in    cases   of   interstitial    keratitis,    glaucoma,    corneal 

opacities,    &c.,    has   done   good.     Place  a   small    portion    of 

ointment  in  the  conjunctival  sac,  close  the  lid  and  massage. 

(9)  Native  Treatment. 

Fumigation  is  done  for  inflammatory  conditions.  Wheat 
grains  are  also  inserted  under  the  deltoid  muscle  for  these 
affections. 

Powders  are  commonlv  used  made  up  of  sugar,  alum  and  lime 
which,  when  mixed,  are  blown  into  the  eye.  In  Arabia  they 
give  a  "  drop  of  mother's  milk." 

Ectropion  is  treated  by  removing  or  pinching  up  the  skin  and 
retaining  it  with  matches.  It  sloughs  and  a  cicatrix  results 
Some  cannot  close  the  eyelids  at  all  afterwards. 

Black  antimony  is  used  to  beautify  the  eyelashes.  This  is 
inserted  with  a  feather,  which  latter  is  a  suitable  vehicle  for 
carrying  the  gonococcus  from  one  to  the  other. 

Cataract  is  treated  by  the  dislocation  of  the  lens  or  couching. 

A  needle  or  thorn  is  passed  through  the  sclera  to  the  pupil  and 
the  lens  is  pressed  down ;  the  patient  jumps  slightly  and  the 
lens  falls.  Some  recover  and  others  become  septic.  There  is 
much  iridocyclitis,  loss  of  vision  and  secondary  glaucoma. 


SI'C'l'loX    \III 


TROPICAL  HYGIENE,  SANITATION,  ETC. 


HYGIENE. 


Climate. 

TKMI'ERATURE. 

Rainfall. 

Sott. 

Constructional  Hygiene. 

Physiological  Effects  of  Hot  Climates  on  Europeans. 

Patiioiocical  Effects  of  Hot  Climates  on  Europeans. 

The  Relation  of  Climate  and  Hygiene  to  Tropical  Diseases. 

Some  General  Rules  for  the  Maintenance  of  Health  in  the  Tropics. 

Epidemiology. 


WATER. 


Amount,    Sourcfs,    Transport,    Pathology,    Control.    Contamination, 
Purification. 


FOOD. 


Nutrition. 

Adulteration  of  Foods. 

So.ME  MoRuiD  Disturbances  caused  by  Food. 

Examination  of  Meats. 

Examinatio.n  of  Living  Animals. 

Meat  Preservation. 

Vegetarianism, 

Infant  Feeding  in  the  Tropics. 

Concentrated  Foods. 

Drinks. 

SANITATION". 

Refuse,  its  Collection,  Removal  and  Disposal. 

Disinfection. 

Quarantine. 

IMMUNITY,  VACCINES  AND   SERA. 

Some  Propiiylactic  Measures  for  Common  Infective  Diseases. 


HYGIENE 


531 


TROPICAL    HYGIENE,    SANITATION,    ETC. 

HYGIENE. 

CLIMATE. 

Castellaxi  defines  climate  as  "  the  combined  effects  of  tlie  sun,  the 
atmosphere,  and  the  earth  at  any  one  place  of  the  earth's  surface." 

The  sun  exercises  its  influence  by  its  heat,  light  and  chemical  ravs. 

The  atmosphere  by  its  chemical  composition,  temperature,  dia- 
thermacy,  humidity,  pressure,  motion  (winds)  and  electric  conditions. 

The  earth  by  its  latitude,  relative  proportion  of  land  and  water, 
ocean  currents,  soil  vegetation,  configuration  of  the  surface  and 
altitude. 

TEMPERATURE. 

Climates  known  as  tropical  and  subtropical  lie  between  35^^  X.  and 
35°  S.  (approximately)  of  the  equator,  the  northern  parallel  being  the 
Tropic  of  Cancer  and  the  southern  being  the  Tropic  of  Capricorn. 

The  sun  is  always  vertical  over  some  part  of  this  broad  belt,  the 
average  mean  temperature  of  which  does  not  go  below  68°  F.  (30°  C). 

When  the  sun's  rays  are  vertical,  80  per  cent,  of  the  sun's  heat 
that  enters  the  atmosphere  reaches  the  earth.  As  the  sun's  ravs  become 
more  oblicjue  less  heat  reaches  the  earth  until  probably  none  reaches 
it,  when  the  sun's  rays  are  horizontal  to  it. 

The  highest  temperatures  are  reached  over  the  two  parallels  men- 
tioned above,  because  the  sun  remains  vertical  for  the  longest  periods 
over  those  parallels. 

The  superficial  land  temperature  may  rise  to  200°  F.  (93*3°  C), 
while  superficial  water  temperature  rarely  exceeds  90°  F.  {^^'2'^  C). 

The  mean  temperature  of  the  earth  increases  with  its  depth,  about 
1°  C.  per  28  metres.  Thus  mines  in  temperate  zones  may  become 
tropical  or  subtropical,  and  consequently  tropical  diseases,  such  as 
ankvlostomiasis,  may  flourish  there  under  suitable  conditions,  e.g-., 
the  tin  mines  of  Cornwall. 

A  daily  range  of  temperature  of  more  than  about  20°  F.  (11°  C.) 
is  apt  to  be  dangerous  if  precautions  are  not  taken.     Short  journeys 


53-2  TROI'ILM.     IIYCIEMi.    SAMTATIOX,     RTC. 

from   (»nc   jjlact*  to  another  with  a   incin    tempera  lure  of  considerable 
variation  must  be  done  at  intervals. 

Health  resorts  can  be  found  in  the  troi)ics  at  hij^jh  altitudes. 
It  is  useful  to  know  that  approximately  the  temjierature  decreases 
1°  F.  for  everv  ,V)()  ffet  of  heij^'ht,  or  i°  C\  for  every  iSo  metres,  hut 
here  aLfain  if  the  mean  average  temperature  is  much  lower  than  that 
of  a  previous  residence,  sick  people  must  approa(  h  it  j^Madually,  in 
stages,  no  matter  how  beneficial  that  altitude  may  be.  This  has  been 
manifested  verv  forcibly  during  the  late  war  in  connection  with 
aviation.  When  aviators  move  very  rapidly  through  varying  atmo- 
spheric pre.ssures  there  are  such  results  produced  upon  the  vital  organs 
of  the  bodv  that  only  selected  persons  can  become  aviators. 

Atmospheric  pressure  is  much  less  on  the  equator  than  about  the 
parallels  of  Cancer  and  Capricorn,  because  the  constant  heating  of 
the  air,  more  or  less  loaded  with  a(|ueous  vajxiur,  ascends  to  high 
altitudes  with  considerable  force.  This  expansion  and  rising  of  air 
is  followed  bv  an  inrush  of  cool  air  from  the  north  and  south  to  fill 
the  space,  hence  if  heat  were  universally  uniform  there  would  not  be 
any  winds.  The  currents  of  air  on  either  side  of  the  equator,  not 
across  the  ocean,  meet  at  the  ef|iiator  and  produce  calms  or 
"  doldrums." 

The  easterly  direction  of  winds  is  due  to  the  rotation  of  the  earth. 
The  air  over  the  land  is  heated  more  rapidly  than  that  over  the  sea, 
hence  the  land  air  rising  is  replaced  by  the  cooler  moist  sea  air,  and 
is  known  as  the  "  sea  breezes."  At  night  the  land,  having  given  off 
its  heat  verv  rapidiv,  is  cooler  than  the  sea,  hence  the  conditions  are 
reversed  and  we  get  "  land  breezes,"  when  wind  comes  from  the  land 
to  the  sea.  Hence  the  pre.sence  of  large  tracts  of  water  have  a  cooling 
inlluence  over  the  adjacent,  land.  'J'he  land  breeze,  being  dry,  is  apt 
to  extract  too  much  moisture  abruptly,  and  cau.ses  a  cooling  process 
which  may  cau.se  serious  chills  and  .so  reduce  one's  resistance  to 
disea.se. 

The  \.I{.  and  .S.W.  nionscrons  of  India  are  explained  by  Dove  as 
follows:  Owing  to  the  heating  of  the  great  plains  of  .Asia,  where  the 
air  ascends  during  the  months  from  May  to  .\iigust,  the  south-east 
trade  wind,  which  is  blowing  .south  from  the  equator,  is  drawn  north- 
wards, at  the  .same  time  being  deflected  to  the  west,  thus  forming  the 
.S.W.  mon.soon.  Conversely,  when  the  plains  cool  from  November 
to  March,  there  is  a  breeze  from  the  north-east  towards  the  equator 
which,  though  known  as  the  X.F..  mon.soon,  is  really  a  trade  wind. 
The  .S.W.  mon.soon  is  laden  with  moisture.  .\  failure  of  the  rain 
from  this  monsoon  means  a  .serious  Indian  famine  accompanied  by 
tens  of  thou.sands  of  deaths. 


HYGIENE  533 

RAINFALL. 

Rain  is  always  cooling,  and  may  be  abundani  in  tropical  countries. 

Tropical  rains  are  usually  very  heavy,  so  that  they  predispose  to 
floods  and  the  formation  of  swamps.  In  India  the  prevailing  winds 
regulate  the  rainy  seasons.  Generally  there  are  two  rainy  seasons 
each  year  between  5°  and  10°  from  the  equator,  one  when  the  sun 
is  on  the  zenith  and  going  away  from  the  equator,  and  the  other  when 
it  is  returning.  Otherwise  there  is  but  one  rainy  season  during  the 
year.  The  violence  of  tropical  rains  is  caused  bv  the  additional 
amount  of  water  that  warm  air  can  take  up,  thus  at  :  — 

20*^  F.  (  7"5'^  C.)  air  takes  up     \';^  grains  of  water  per  cubic  foot 
60°  F.  ds-S"  C.)  „  S77 

85^'  F.  (29f/'  C.)  „  1278 


When  saturated  air  at  85°  F.  (29-6  C.)  is  cooled  to  60°  F.  (15-8°  C.) 
every  cubic  foot  will  yield  seven  grains  of  water  (Hill). 

Owing  to  the  excessive  heat  and  moisture  in  the  tropics,  putre- 
faction and  fermentation  are  very  rapid  and  often  dangerous  to  man. 

SOIL. 

Soil  affects  the  temperature  by  its  power  of  absorption  and 
radiation  and  its  vegetation.  Sandy  soils  are  hottest  and  emit  a  glare 
which  is  very  trying  to  the  eyes.  Clayey  soils  are  coolest  because  of 
the  water  they  hold.  They  cause  a  high  atmospheric  humidity,  retard 
evaporation  and  radiation.  The  climate  in  consequence  is  made  more 
ecjuable,  but  more  oppressive  and  predisposing  to  rheumatic  troubles 
and  chest  diseases. 

Soil  temperature  varies  but  slightly  at  a  depth  of  8  feet  below 
the  surface,  and  is  not  affected  at  all  at  a  depth  of  40  feet  (Galton). 
Trees  and  shrubs  intercept  the  sun's  rays  and  check  evaporation  from 
the  soil  and  thus  render  the  ground  cooler. 

Evaporation,  however,  is  great  and  takes  much  moisture  from  the 
soil. 

In  Algeria  the  Eucalyptus  globulus  absorbed  and  evaporated 
twelve  times  the  rainfall.  Grass  renders  soil  cooler,  drier,  and  of  more 
equable  temperature. 

When  soil  is  permanently  damp  it  is  injurious  to  health.  In  order 
to  keep  the  subsoil  water  at  a  low  level  subsoil  drains  must  be  put  in, 
periodically  cleaned  and  relaid. 

A  permanent  dampness  mav  be  due  to  :  — 

(i)  Clayey  soils  that  do  not  drain  themselves  readily,  thus  forming 
swampy  and  mosquito  breeding  grounds. 

(2)  By  an  impervious  layer  approaching  the  surface  at  a  given  place 
and  bringing  the  subsoil  water-level  higher  than  it  otherwise  would 
be.     This  level  should  always  be  5  feet  below  the  surface. 


534  TROI'IL.IL    HYGIRXE.    SAX  IT  ATIOX ,     HTC. 

(3)  I>\  ((b.siriiciccl  dr.iina.ijr  rcsiiltiii}^^  Irom  railway  fmbaiikmenls, 
excavations,  &r.,  resuliin.tr  from  such  cunsiruriional  works.  Also  by 
sand  pits  and  clay  holes. 

(4)  15v  the  backwater  from  obstructed  rivers,  blocking  up  the  house 
drains  by  its  refu.se. 

(5)  Bv  sullaj^e  water  when  a  water  .system  has  been  provided  with- 
out the  nece.s.sary  drainage  for  waste  water. 

(6)  At  (tr  near  the  irregularities  of  the  earth's  surface,  as  at  the 
f(X)t  of  hills  and  low-lyinj^  country.  Such  |)Iaces  are  often  flooded 
for  months  after  the  rains. 

(7)  Hv  tile  effects  of  lar<^e-scale  irrijj^alions,  unaccompanied  b\ 
efticient  drainaj^e.  To  correct  this  latter  fault  the  Indian  Sanitary 
jx)wers  have  laid  down  the  following  regulations:  — 

(i)  The  irrigation  canals  to  be  constructed  along  the  line  of  the 
watershed. 

(2)  The  smaller  canals  to  be  so  constructed  as  not  to  be  carried 
across  tiie  natural  lines  of  drainage. 

(3)  Drainage  cuts  to  be  constructed  along  the  natural   lines  of 
outfall. 

(4)  The  supply  of  water  to  be  limited  lo  the  amount  required, 
and  to  the  particular  time  needed  to  secure  the  success  of  the  crops. 

The  Government  of  (he  Soudan  have  introduced  the  following 
regulations  in   regard  to  irrigation  :  — 

(i)  Irrigation  channels  should  be  constructed  on  a  higher  level 
than  the  surrounding  ground,  so  that  when  :he  flow  of  water  in  them 
ceases  they  may  drain  dry. 

(2)  Thev  should  be  constructed  of  such  material,  and  in  such  a 
manner  as  to  prevent  leakage. 

(3)  Their  banks  and  beds  should  be  kept  in  good  repair  and  the 
beds  even  to  |>revent  the  formation  of  pools. 

(4)  "  Dead  ends  "  of  irrigation  <  hannels  should  be  reduced  to  liie 
smallest  size  compatible  with  efficiency,  so  that  water  will  not  stagnate 
in  them. 

(5)  \  egetation  should  be  pericxlically  cleared  out  of  the  channels. 

(6)  Sluices  should  be  ccjnslructed  so  that  there  is  no  leakage  to 
form  stagnant  puddles. 

(7)  Where  possible  fish  should  be  introduced,  and  kept  in  the 
main  channels  to  destroy   larv.e. 

(8)  Lands  where  water  is  apt  to  stand  should  have  proper  surface 
drains. 

(())  Crops,  such  as  sugar  cane,  rice,  or  others,  which  require  to 
stand  in  water,  should  not  be  grown  within  a  mile  of  any  town  or 
village. 


HYGIENE  535 

(lo)  In  the  event  of  an  engine  or  jDump  breaking  down,  particular 
care  should  be  taken  to  deal  with  stagnant  pools,  and  petroleum 
should  be  used  where  necessary. 

(ii)  Malarial  fever  and  excessive  numbers  of  mosquitoes  should 
be  notilied  to  the  Governor  of  the  province  by  the  manager  of  the 
concession. 

Rice-bearing  ground  must  be  closely  watched  and  well  controlled 
lo  avoid  mosquito  breeding,  otherwise  cultivation  decreases  the 
healthiness  of  the  soil. 

Ground  air  must  be  cut  off  from  tropical  dwellings  by  having  a 
basement  or  foundations  in  cement  or  other  impermeable  material. 

Loose  sand  mav  contain  50  per  cent,  of  ground  air. 

Ground  air  contains  moisture,  organic  matter  of  animal  origin, 
sometimes  of  vegetable  origin,  also,  in  consequence,  ammonia, 
hydrogen  sulphide,   marsh  gas  and  carbon  dioxide  in  excess. 

The  ground  air  is  in  constant  movement  as  a  result  of  the  wind, 
percolation  of  the  rain,  varieties  of  temperature  and  barometric 
pressure,  also  by  the  rise  and  fall  of  the  ground  water  level. 

Organisms  exist  in  the  soil  in  abundance,  nitroso  bacteria  (nitrous 
organisms),  nitro  bacteria  (nitric  organisms).  These  are  found  within 
I J  inches  of  the  surface.  B.  tetanus  is  world-wide.  B.  anthracis, 
bacillus  of  malignant  oedema  and  B.  typhosus  may  survive  twenty 
weeks  in  the  soil.     The  B.  coli  exists  in  the  soil,  but  for  shorter  periods. 

CONSTRUCTIONAL  HYGIENE. 

Building  Site. 

In  selecting  a  site  for  a  house,  choose  the  side  of  a  hill  awa}'  from 
the  native  quarters  and  secure  natural  drainage. 

Tablelands  are  always  good.  Avoid  all  depressions,  feet  of  hills, 
ravines  and  narrow  valleys.  Avoid  a  luxuriant  fertile  soil  which 
means  dense  vegetation.  What  is  good  for  vegetation  is  bad  for  man. 
Select  a  dry  site,  granite  if  possible;  "  build  your  house  upon  a  rock." 

Good  water  should  be  accessible. 

Clear  all  bush  for  200  metres  from  the  nearest  dwelling.  Leave 
high  trees.  Plant  Bahama  or  Kasai  grass,  but  keep  it  cut  short  or 
it  will  harbour  mosquitoes. 

There  should  be  a  slope  from  the  house  in  all  directions  if  possible, 
with  small,  shallow,  open  drains  to  carry  off  the  water. 

The  House. 

Mosquito-proofed  brick  houses,  raised  from  the  ground,  \\\{\\  a 
broad  verandah  are  most  suitable  for  the  tropics. 

The  rooms  and  verandahs  should  be  ceiled  to  form  a  ventilated 
air  space  under  the  roof.     The  rooms  should  be  lofty  and  boarded. 

34 


536  TROPICAL    HYGIENE,    SANITATION,    ETC. 

If  there  is  any  glass  in  the  windows  it  should  be  shaded  from  the 
direct  sunlight  by  screens.  Through  ventilation  is  essential  in  all 
good  houses.  There  must  be  a  very  good  damp  course  in  cement 
around  all  the  walls.  It  should  be  remembered  that  an  ordinary  brick 
holds  1 6  ounces  of  water. 

One  must  insist  on  the  instant  removal  of  every  impurity  and 
household  refuse  bv  burial  or  fire.  One  should  avoid  windowless 
cubicles  and   narrow  passages.     The  kitchen  should  be  built  apart. 

Villages,  Camps  and  Stations. 

The  houses  should  be  built  along  the  lines  indicated  as  far  as 
possible.     Always  plan  and  plot  as  for  a  larger  settlement. 

Construction  must  be  controlled  or  every  cluster  of  dwellings  will 
become  a  death-trap.  Make  all  streets  of  one-storeyed  houses  30  feet 
wide  (10  metres),  and  those  for  double-storeyed  houses  50  feet  wide 
(18  metres).  The  principal  streets  should  be  60  to  100  feet  wide  (22  to 
36  metres).  All  streets  should  be  parallel  to  or  at  right  angles  with 
each  other  and  shaded  by  suitable  trees. 

All  ordinary  houses  should  be  in  alignment  with  one  of  the  streets. 
If  a  township  is  anticipated  plan  for  a  large  population,  and  allow  for 
open  spaces,  gardens,  recreation  grounds,  schools,  hospitals,  ceme- 
teries, latrines,  wash-houses,  &c.  All  proposed  buildings  should  be 
submitted  b^'  plan  to  the  responsible  authorities  before  their  con- 
struction. Consider  the  possible  demands  for  tram  lines,  rail  roads, 
&c.  Provide  a  lane  15  to  20  feet  (5  to  7  metres)  wide  for  sanitary 
purposes  at  the  back  of  each  row  of  houses.  This  will  also  serve  for 
drainage,  scavenging,  air  space,  &c.  It  will  also  prevent  encroach- 
ments and  will  facilitate  alignment. 

Native  villages  should  be  on  a  health v  site,  well  av\ay  from  any 
European  dwellings.  The  huts  should  be  of  brick,  daub  or  ant-hill 
clay  with  a  grass  roof.  Such  are  cool,  but  the  usual  iron  buildings 
are  insufferably  hot,  even  to  a  native.  There  should  be  permanent 
openings  below  the  wall-plates  for  ventilation.  The  houses  should 
not  be  more  than  16  feet  in  height  (5  metres)  and  built  along  a  road- 
way, 30  feet  (10  metres  wide).  Nine  feet  (3  metres)  should  be  allowed 
between  detached  huts.  They  should  be  properly  constructed  with 
a  latrine  for  each,  and  a  back  lane,  parallel  with  the  road,  15  feet 
(5  metres)  wide. 

Jails. 

Formerly  they  were  the  endemic  centres  of  bacillary  dysentery. 

At  the  present  time  much  improved  buildings  are  being  erected. 

The  site  area  should  be  50  square  yards  (50  square  metres)  for  each 
prisoner.  The  dormitories  should  be  20  feet  (6  metres)  wide  and 
12  feet  (4  metres)  high  with  two  rows  of  beds,  one  on  either  side  and 


HYGIENE 


537 


a  good  passage  bet^veen  them.  Each  bed  should  have  36  square  feet 
(4  square  metres),  for  the  hospital  54  square  feet  (6  square  metres)  each 
(Bengal  Jail  Code).  Solitary  cells  should  have  75  superficial  feet 
(8  metres)  and  a  cubic  space  of  1,000  feeto 

Drinking  water  must  be  sterile.     Latrines  must  be  well  controlled. 

If  a  prisoner  loses  more  than  four  pounds  in  weight  in  two  weeks 
he  should  be  sent  to  the  Medical  Officer. 

PHYSIOLOGICAL  EFFECTS  OF  HOT  CLIMATES  ON  EUROPEANS. 

The  effects  of  hot  climates  upon  individuals  vary  according  to  the 
humidity,  altitude,  sedentary  occupation,  town  or  countrv  life,  habits, 
&c.  The  climate  has  been  blamed  for  much  that  has  been  due  to 
insanitarv  conditions,  alcoholism  and  other  excesses,  but  when  all 
pathological  conditions  are  ruled  out  the  following  generally  hold  good 
until  acclimatization  has  taken  place,  a  process  requiring  two  to  four 
years  :  — 

(i)  There  is  a  greater  supply  of  blood  to  the  surface  of  the  body 
accompanied  by  excess  of  skin  functions,  e.g.,  pigmentation  and 
increased  perspiration.  Persons  who  cannot  perspire  should  not 
reside  in  tropical  countries,  as  perspiration  is  the  chief  means  of  main- 
taining a  normal  body  temperature. 

(2)  The  body  temperature  of  an  European  in  the  tropics  is  slightlv 
above  the  normal  until  thoroughly  acclimatized.  It  is  increased 
o"05°  F.  for  every  1°  F.  increase  above  the  average  normal  temperature. 
Exercise,  tight-fitting  and  unsuitable  clothing  will  raise  the  body 
temperature. 

(3)  Owing  to  the  modified  distribution  of  the  blood,  the  capacitv 
of  the  lungs  increases,  more  blood  is  drawn  out  and  more  air  enters, 
thus  reducing  the  weight  of  the  lungs.  As  respirations  are  decreased 
in  number  the  lungs  actually  do  less  work  than  in  temperate  countries. 
One  must  also  remember  that  tropical  air  is  rarefied  and  contains  less 
oxygen  than  cold  air,  consequently  less  carbon  dioxide  is  taken  off  in 
a  given  time,  and  there  is  a  tendency  to  retain  carbonaceous  matter 
in  the  blood. 

Nine  per  cent,  less  oxygen  in  inspired  at  80°  F.  (27°  C.)  than  at 
32°  F.  (0°  C). 

(4)  As  the  pulse  is  slowed  and  respiration  slightlv  impaired  the 
heart's  action  is  weakened  and  the  vital  organs  are  less  well  nourished; 
hence  there  are  diminished  vigour,  general  debility,  anaemia, 
irritabilitv,  nervous  depression,  sleeplessness  and  irritabilitv  (the 
tropical  fury  of  Phehn). 

(5)  O'Connell  in  1909  sought  to  show  that  exposure  to  a  damp- 
tropical    climate    could    cause   an    intermittent    fever   with    haemolysis. 


538  TROPICAL    HYGIENE,    SANITATION,    ETC. 

poikllocytosis,  melanjemia  and  enlarged  spleen.    This  is  not  commonly- 
held. 

(6)  The  urine  is  diminished  in  quantity  and  in  solids. 

(7)  The  generative  organs  act  more  vigorously. 

(8)  Menstruation  begins  one  year  earlier  with  European  girls  living 
in  the  tropics. 

(9)  The  children  of  European  parents  residing  in  the  tropics  during 
the  active  stages  of  growth  are  generally  weaker  than  their  brothers 
and  sisters  of  temperate  climes. 

(10)  The  effects  of  the  sunlight  are  dealt  with  elsewhere.  During 
the  two  to  four  years  of  acclimatization  tropical  residents  are  especially 
liable  to  disease  from  diminished  resistance  of  both  body  and  mind. 
Acclimatization  for  permanent  residence  of  Europeans  in  the  tropics 
does  not  take  place. 

Anderson's  views  upon  this  subject  are  as  follows  :  — 

(i)  When  a  white  species  is  well  adapted  to  the  conditions  which 

environ  it,   it   flourishes;  when   imperfectly  adapted,   it  decays;  when 

ill  adapted,  it  becomes  extinct. 

(2)  When  a  white  man,  a  native  of  the  temperate  zone,  goes  to 
the  tropics,  there  occurs  a  biological  reaction  of  his  system  to  the  new 
environment,  and  a  readjustment  of  co-ordination  between  his  vital 
processes. 

(3)  In  the  tropics  the  white  man,  individually,  can  exist ;  racially, 
he  cannot  exist. 

(4)  Acclimatization  is  not  possible. 

(5)  No  superior  race  can  successfully  govern  an  inferior  race 
superior  in  numbers  with  equality  before  the  law. 

(6)  Onlv  by  partial  enslavement  of  the  coloured  natives,  superior 
in  numbers,  can  the  white  man  rule  and  govern  the  tropics,  and  it  is 
only  by  relays  of  fresh  representatives  that  he  can  continue  his 
sovereignty. 

{7)  Xo  colony  of  northern  origin  has  ever  been  able  to  lead  a 
permanent  and  independent  existence  in  the  tropics. 

To  obtain  the  best  results  all  excesses  must  be  avoided,  while  daily 
baths  and  exercise  should  be  carried  out  religiously. 

PATHOLOGICAL  EFFECTS  OF  HOT  CLIMATES  ON  EUROPEANS. 

Those  effects  not  due  to  parasites  are  of  congestive  or  nervous 
origin.  The  abstraction  of  heat  by  the  cool  evening  breezes  often 
causes  congestion  leading  to  chills  and  predisposing  to  disease.  At 
such  times  the  blood  leaves  the  surface  of  the  body  and  concentrates 
in  the  viscera,  such  as  the  spleen  and  liver,  causing  congestion  in 
them.     Excessive  exercise  and  alcohol  will  produce  the  same  effects. 


HYGIENE 


539 


The  sun's  ra}'s  will  cause  congestion  of  the  skin,  followed  by 
increased  pig-mentation,  sunburn,  dermatitis,  and  probablv  xeroderma 
pigmentation. 

Heat  exhaustion  is  perhaps  due  directly  to  meteorological  con- 
ditions, but  sunstroke  and  siriasis  are  not  so  easy  to  explain.  For 
details  of  these  two  disorders  see  separate  section. 

Neurasthenia  is  almost  universal. 

Loss  of  memory  is  common,  especially  on  the  West  Coast  of 
Africa,  where  it  is  known  as  "  Coast  Memory." 

THE  RELATION  OF  CLIMATE   AND   HYGIENE   TO  TROPICAL 

DISEASES. 

A  few  of  the  outstanding  features  onlv  will  here  be  dealt  with  as 
these  diseases  are  described  elsewhere. 

Asiatic  Cholera. 

This  disease  often  subsides  or  disappears  in  the  winter  and  in 
temperate  climates,  but  it  reappears  witli  the  warm  weather  without 
fresh  introduction;  hence  heat  is  an  important  predisposing  cause  of 
the  disease.  Heat  is  not  all,  however,  for  if  the  temperature  is  rising, 
as  in  Calcutta  during  April  and  May,  and  the  rainy  season  sets  in, 
cholera  is  diminished,  but  when  the  rains  cease  in  November  it  again 
increases,  for  at  this  time  the  temperature  again  falls.  A  moist  soil, 
prolonged  heat  and  drought  are  the  best  conditions  for  the  spread  of 
the  disease. 

It  is  a  water-borne  disease;  hence  no  water  should  be  allowed  to 
become  polluted,  and  all  water  should  be  sterilized  before  drinking. 

Insanitary  conditions  of  air,  water,  food,  soil,  drainage  and  housing 
determine  the  point  of  attack. 

Yellow  Fever. 

This  disease  is  endemic  only  where  the  mean  temperature  reaches 
68°  F.  (20°  C).  Frost  always  arrests  it.  I'nless  the  temperature  is 
very  low,  atmospheric  humiditv  and  rainfall  favour  it. 

It  is  limited  to  the  sea  coasts  and  the  mouths  of  great  rivers. 

It  is  seldom  found  over  700  feet  high. 

The  disease  commences  usually  in  the  most  crowded  and  filthiest 
quarter  of  the  town  or  ship  if  similar  conditions  prevail. 

As  the  ultra-microscopic  virus  is  mosquito-borne  (Stegomyia 
calopus),  all  conditions  favourable  for  mosquito  breeding  are  favour- 
able for  the  spread  of  the  disease,  e.g.,  no  mosquitoes,  no  yellow 
fever. 

Plague. 

This  is  an  infectious  disease  of  filtli  that  has  robbed  India  alone 
of  more  than  7,000,000  of  its  inhabitants.  It  is  fostered  by  filth, 
overcrowding,   lack  of  ventilation  and  destitution. 


540  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Malarial  Diseases. 

Given  the  parasite  and  the  mosquito,  malaria  tends  to  increase  with 
the  temperature.  Atmospheric  humidity  favours  it  by  encouraging 
mosquito  breeding  and  by  predisposing  to  chills  in  European  residents. 
Clay  soil  is  bad  on  account  of  the  high  subsoil  water  which  encourages 
mosquito  breeding.  Complete  temporary  flooding  or  good  draining 
will  reduce  its  incidence  anywhere.  Its  prevalence  decreases  with 
altitude,  other  things  being  equal. 

Relapsing  Fever. 

Neither  soil  nor  climate  affect  this  disease. 

Destitution,  tilth  and  overcrowding  are  powerful  predisposing 
causes.  These  conditions  favour  the  presence  of  the  soft  ticks,  e.g., 
Ornithodorus  moubata  and  Argas  persicus,  which  are  blamed  as 
carriers  of  the  disease. 

Leprosy. 

Climate  and  tropical  conditions  exercise  but  little  influence  upon 
this  disease.  Sanitary  improvements  in  habits  and  surroundings  will 
certainly  assist  in  suppressing  it.  It  has  been  called  a  disease  of 
semi-civilization. 

Undulant  Fever. 

This  disease  is  carried  largely  by  the  infected  milk  of  infected 
goats.     It  is  also  carried  by  water. 

Pellagra. 

The  eruption  recurs  each  spring  and  autumn.  Exposure  to  the 
sunlight  is  a  strong  predisposing  factor  of  the  eruption. 

The  symptoms  abate  during  the  summer  and  almost  disappear  in 
winter.     Agricultural  classes  are  most  aft'ected. 

It  is  almost  world-wide  in  its  distribution. 

Trypanosomiasis. 

Insanitary  conditions  favour  the  breeding  of  the  Glossin^e  which 
are  necessary  for  its  propagation.  Destitution  predisposes  to  the 
disease  and  raises  the  case  incidence  and  mortality. 

Dysentery. 
Personal    cleanliness    is    absolutely    essential    on    the    part    of    the 
patients  and    carriers.     Excreta   are   the   chief    factors    of    its    spread. 
Poverty,    overcrowding  and   debility   give   good   ground   for  bacterial 

dysentery. 

Beriberi. 

This  is  a  deficiency  disease  in  all  probability.  The  best  food  under 
the  best  hygienic  conditions  will  prevent  its  onset  and  spread. 


HYGIENE  541 

Dengue. 

Its  prevalence  is  greatest  in  the  hot  season.  It  affects  maritime 
towns  and  seldom  spreads  inland.  Low-lying,  filthy  and  overcrowded 
quarters  are  the  first  attacked. 

SOME  GENERAL  RULES   FOR  THE   MAINTENANCE  OF   HEALTH 

IN  THE  TROPICS. 

All  defective  teeth  should  be  corrected  by  a  qualified  dentist  before 
the  traveller  leaves  Europe. 

It  is  preferable  to  abstain  absolutely  from  alcohol. 

If  alcohol  is  taken  it  should  be  in  great  moderation  after  sunset. 

Take  a  dail_v  tepid  bath,  preferably  at  sundown,  before  food. 

Cold  baths  are  tmsafe  for  all  who  have  any  bowel  weaknesses. 

Judicious  exercise  is  of  great  value,  taken  in  the  earl}-  morning  or 
the  late  afternoon,  such  as  golf,  cricket,  croquet,  polo  and  tennis. 

Chills  afterwards  should  be  avoided. 

The  great  temptation  to  lead  a  sedentary  life  must  be  overcome. 

A  muslin  mosquito  net,  twenty  strands  to  the  inch,  tucked  under 
the  mattress  one  hour  before  sundown,  and  kept  in  good  repair,  is 
essential. 

High  boots,  leggings,  or  puttees  are  of  great  value  for  all  travel- 
ling through  bush  for  the  protection  of  the  legs  from  snake  and  insect 
bites. 

Light  khaki  clothes  with  spine  pads  for  the  bush  and  white  drill 
for  the  stations  and  evenings  are  best.     Wool  is  irritable  to  the  skin. 

A  mixture  of  wool-silk  is  comfortable,   e.g.,   Anglo-Indian  gauze. 

Silk  next  to  the  skin  may  be  necessary  for  those  whose  skins  are 
irritable  as  a  result  of  perspiration,  &c. 

All  personal  servants  sliould  take  a  daily  bath  and  be  free  from 
infectious  disease. 

All  water  should  be  boiled  and  filtered.  It  is  a  good  plan  to  drink 
weak  tea  or  coffee  instead  of  water,  as  this  ensures  the  water  having 
been  boiled.  If  a  filter  is  not  obtainable  a  little  alum  added  to  the 
water  is  useful.     Boil  it  after  standing. 

Keep  all  food  supplies  awav  from  flies  in  a  gauze  receptacle. 

All  fresh  milk  must  be  boiled. 

Take  Cjuinine;  hvdrochloride  is  better  than  the  sulphate,  5  grains 
daily,  except  Sundays,  when  take  2  grains  of  calomel,  followed  by  half 
an  ounce  of  Epsom  salts. 

Jaeger  sleeping  sacks  are  useful  for  those  sleeping  out. 

Always  dress  according  to  the  temperature,  and  not  according  to 
appearances  and  the  "  climate." 

After  perspiring  change  clothes  frequently. 


542  TROPICAL    HYGIENE,    SANITATION,     ETC. 

Take  an  hour's  rest  during  the  hottest  part  of  the  day. 

Food  should  be  well  cooked,  excess  of  meat  and  fat  avoided,  fresh 
fruits,  salads  and  vegetables  should  be  sought  after  and  substituted 
for  the  salted  meat  and  rum  of  olden  days.  The  effects  from  over 
indulgence  of  alcohol  are  m^u'ked. 

If  possible,  it  is  advisable  to  spend  the  hottest  months  at  a  greater 
elevation.  The  next  best  thing  is  to  use  fans  and  punkahs  to  avoid 
heat  debility. 

Cholera  bells  are  not  necessary  for  healtliy  individuals,  and  to  such 
are  often  a  source  of  discomfort  A\hen  worn. 

It  is  absolutely  essential  to  protect  oneself  from  the  sun's  rays. 

The  measures  to  be  adopted  are  as  follows  :  — 

Wear  a  light,  well-ventilated  pith  or  rubber  helmet  or  topee  with 
a  broad  brim  and  a  prolongation  for  the  neck.  A  white  covering  is 
best  as  it  reflects  the  heat,  but  does  n<3t  absorb  it.  The  helmet  may 
transmit  chemical  rays,  and  hence  it  is  best  that  it  should  be  lined 
with  coloured  material. 

For  those  stooping  at  their  work  spine-pads  are  essential. 

Broad  verandahs  should  be  added  to  all  buildings. 

Reflection  of  tlie  sun's  rays  from  the  floors  must  be  avoided. 

There  should  be  ventilated  ceilings  to  all  dwellings. 

The  roads  should  be  shaded  with  trees  having  spreading  branches. 

Plots  of  green  grass  will  prevent  the  glare  from  the  sun. 

Alcohol  is  the  most  predisposing  cause  of  sunstroke. 

Smoked  glasses  are  very  comforting  from  the  glare.  The_y  will 
often  prevent  the  onset  of  troublesome  eye  symptoms. 

EPIDEMIOLOGY. 

Communicable  diseases  may  manifest  themselves  in  one  of  four 
ways  when  one  of  the  following  terms  is  applied  to  it  :  — 

(1)  Sporadic. 

A  disease  is  sporadic  when  cases  occur  singly  or  in  small  groups 
in  scattered  communities,  e.g.,  typhoid  fever,  undulant  fever,  &c. 
Such  sporadic  cases  may  precede  endemic  or  epidemic  manifestations, 
and  should  always  be  closelv  watched  and  controlled. 

A  sporadic  disease  may  at  certain  times  and  places  become 
endemic,  epidemic  and  sometimes  pandemic,  such  as  undulant  and 
typhoid  fever.     The  divisions  are  purely  arbitrary. 

(2)  Endemic. 

A  disease  is  endemic  A\hen  the  cases  attach  themselves  more  or  less 
to  a  certain  district  or  localitv,  e.g.,  cholera  in  the  delta  of  the  Ganges; 
leprosy  in  parts  of  Norway,  &c. 


HYGIENE  543 

These  are  often  considered  by  those  residing  in  the  endemic  area 
to  be  some  of  the  unavoidable  ills  to  which  man  is  heir. 

(3)  Epidemic. 

A  disease  is  said  to  be  epidemic  when  the  cases  are  widely  prevalent 
over  a  larger  or  smaller  area.  Epidemic  diseases,  as  a  rule,  tend  to 
spread  rapidly  and  to  attack  fresh  communities. 

Examples  are  small-pox,  \'ellow  fever,  cholera,  plague,  dengue, 
trvpanosomiasis,  relapsing  fever,  anthrax,  &c.,  though  some  of  these 
are  limited  in  their  distribution  by  the  prevalence  of  their  carriers, 
e.g.,  the  mosquito,  glossina\  rat  and  rat  flea,  bugs,  &c. 

(?)  Pandemic. 

A  disease  is  said  to  be  pandemic  when  the  cases  become  diffused 
over  most  parts  of  the  world,  as  influenza  from  Russia  and  plague 
from  India. 

The  study  of  the  modes  of  the  transmission  of  communicable 
diseases  increases  much  with  the  opening  of  new  means  of  intercourse 
between  countries  and  continents,  e.g.,  the  Suez  Canal,  the  Trans- 
Siberian  Railw^ay,  the  Panama  Canal,  &c.  For  example,  plague  may 
be  brought  from  Guayacjuil  on  the  Pacific  Coast,  where  it  is  endemic, 
and  introduced  via  the  Panama  Canal  into  countries  where  it  has  been 
obliterated,  e.g.,  England.  The  arrival  of  one  plague-infected  rat  in 
Liverpool  from  Japan  caused  a  consternation  in  that  cit}'  only  a  few^ 
months  ago.  There  were  eight  cases  of  plague  brought  to  London  in 
October,    1919. 

When  studying  the  question  one  has  to  consider  the  carriers  and 
conditions  under  which  the  disease  thrives.  For  example,  if  there  are 
no  mosquitoes  (Stegomyia  calopus)  in  the  country  of  arrival,  one  need 
not  be  over-anxious  about  importing  a  case  of  yellow  fever,  just  as 
one  does  not  hesitate  to  send  to  Europe  cases  of  trypanosomiasis  from 
infected  areas  to  places  where  there  are  not  any  Glossin^e. 

There  are  many  other  factors  to  be  considered  as  locality,  climate, 
season,  surrounding's,  age  and  sex  of  those  exposed. 

The  spread  of  ankylostomiasis  needs  heat  and  moisture;  cold  will 
cut  off  the  epidemic  at  once  and  define  its  margins.  Likewise,  bil- 
harzial  disease  requires  molluscs;  no  molluscs,  no  bilharzial  disease. 
The  old  theories  of  air  dissemination  are  in  the  main  exploded,  they 
being  but  a  cloak  for  our  ignorance,  as  the  old  term  "  eczema  "  was 
for  skin  diseases  in  general. 

The  whole  facts  affecting  the  spread  of  these  diseases  are  not  yet 
^\ell  understood  even  in  advanced  countries.  We  do  not  know  why 
scarlet  fever  should  tend  to  become  epidemic  at  intervals  of  five  years 
in  temperate  climates  where  it  has  become  established. 

The  same  applies  to  measles,  which  tends  to  be  epidemic  every  two 


544  TROPICAL    HYGIENE,    SANITATION,     ETC. 

years.  Whooping-cough  of  uncertain  causation  shows  no  marked 
periodicity,  but  tends  to  become  epidemic  every  two  years  on  an 
average. 

WATER. 

WATER— AMOUNT. 

One  should  estimate  for  about  15  gallons  per  head  per  diem  for 
personal  and  domestic  use,  made  up  as  follows  :  — 

Domestic  washing...         ...         ...         ...  4  gallons 

Ablutions     ...         ...         ...         ...         ...  3       „ 

General  baths         ...         ...  4       ,, 

W.c 4       M 

One  should  allow  for  a  little  waste  in  excess  of  this. 

In  towns  ID  gallons  per  head  should  be  allowed  daily  for  municipal 
purposes,  and  if  trade  processes  are  at  all  numerous  another  10  gallons 
should  be  added. 

Hence,  roughly,  one  may  say  provide  :  — 

12  gallons  per  head  per  diem  where  there  are  no  w.c.'s. 
16       „  „  ,,  are  w.c.'s. 

36       „  ,,  in  large  towns  generally 


WATER— SOURCES. 

All  natural  waters,  springs,  rivers,  lakes,  &c.,  are  derived  ultimately 
from  rainfall,  which  is  water  taken  up  from  humid  surfaces  of  the 
earth,  distilled  under  the  influence  of  the  sun's  rays  and  distributed 
to  the  earth  afresh. 

Part  of  the  rainfall  is  quickly  evaporated.  Some  of  it  flowing 
above  an  impervious  layer  finds  its  way  into  shallow  springs,  streams 
and  lakes.  The  remainder  sinks  below  the  surface  below  an  imper- 
vious layer,  when  it  may  form  deep  springs. 

Bodies  of  water  may  lie  in  large  "  pockets  "  either  just  above  or 
below  an  impervious  stratum ;  in  the  former  case  surface  wells  can  be 
dug,  and  in  the  latter  deep  wells  will  be  required  in  order  to  obtain 
it.  A  deep  well,  however,  may  not  be  so  deep  as  a  shallow  well,  the 
difference  being  according  to  the  nearness  to  the  surface  of  the  imper- 
vious layer. 

Ninety  per  cent,  of  rain  water  sinks  below  the  soil  surface  in  sandy 
and  gravel  districts,  while  a  clayey  soil  permits  of  an  exceedingly  small 
filtration. 

In  places  where  rainfall  is  scanty,  as  at  Aden,  or  only  salt  water 
is  available,  as  on  the  ocean  and  on  salt  lakes,  drinking  water  is 
obtained  by  the  distillation  of  the  salt  water. 

This  process  is  carried  out  for  the  European  residents  and  troops 
at  Aden,  for  the  miners  on  some  Australian  mines  and  on  board  war 
and  other  vessels. 


WATER  545 

Distilled  water  can  be  aerated  at  the  same  time  by  a  Normandy's 
condenser.  On  British  warships  five  gallons  per  man  per  diem  is 
distilled  and  aerated. 

In  land  districts  where  there  are  no  rivers,  wells,  or  storage  tanks 
for  the  rainfall,  boring  should  be  carried  out.  This  should  be  done 
in  a  hillv  country  for  preference.  The  required  depth  will  depend 
upon  the  distance  from  the  surface  of  the  impervious  layer. 

Select  the  following  places  for  experimental  borings  :  — 

(i)  Under  dry  river  beds. 

(2)  At  the  junction  of  ravines  and  valleys. 

(3)  At  the  foot  of  hills. 

(4)  In  a  thickly  w^ooded  country.  When  a  country  is  cleared  of 
vegetation  and  timber,  the  rain  water  flows  away  very  rapidly  and 
permanent  streams  are  few. 

(5)  Examine  along  the  line  of  any  geological  fault  in  the  part. 

(6)  Test  localized  areas  over  \vhich  fogs  or  swarms  of  insects  are 
noticed  in  the  early  morning. 

(7)  Limestone  and  sandstone  districts  are  good  for  deep  wells,  but 
unfortunately  there  are  large  inland  areas  where  such  do  not  exist. 

We  will  now  deal  with  the  subject  under  three  heads,  viz.  :  Rain 
Water;  Surface  Water;  Subterranean  Water. 

Rain  Water. 

Rain  water  is  soft,  well  aerated  and  pure,  apart  from  the  impurities 
taken  up  by  it  from  the  atmosphere.  It  also  absorbs  atmospheric 
gases,  such  as  carbon  dioxide,  oxygen  and  nitrogen,  the  last  two  in 
the  proportion  of  8  and  i6'5  per  litre. 

Tropical  rain  water  varies  much  in  quantity,  from  600  inches  per 
annum  at  Cherrapunji,  in  India,  to  rainless  desert  tracts.  At  Aden 
rain  may  not  fall  for  several  years. 

Rain  water  may  be  collected  from  the  roofs  and  stored  in  tanks,  or 
from  large  surface  areas  made  impermeable  by  cement,  &c.,  and  stored 
as  at  Gibraltar.  When  collected  from  iron  roofs  the  latter  should  not 
be  painted,  as  the  paint,  containing  lead,  may  lead  to  lead  poisoning. 

In  some  parts,  as  in  the  Choco,  Colombia,  there  is  nearly  one  inch 
of  rainfall  every  night  all  the  year  round,  so  that  permanent  storage  is 
not  required  and  fresh  w-ater  is  always  available. 

Birds  should  ahvays  be  kept  off  collecting  roofs  as  they  pollute  the 
water.  Wires  should  be  placed  above  and  along  the  ridges  and  the 
guttering  to  keep  them  off. 

In  rainy  districts  pollution  from  the  dust  and  decayed  vegetation 
does  not  arise. 

To  determine  the  rain  water  available  it  is  necessary  to  know  two 
things  :  — 


546  TROPICAL    HYGIENE,    SANITATION,    ETC. 

The  annual  rainfall  in  inches  as  ascertained  by  a  rain  gauge. 

The  sc|uare  inches  of  sectional  area  of  the  building  (not  the  slant 
surface  of  the  roof). 

The  annual  rainfall  in  inches  multiplied  by  the  square  inches  of 
sectional  catchment  areas  equals  the  cubic  inches  of  water  per  annum. 
This  multiplied  again  by  0*0036  gives  the  number  of  gallons  per 
annum. 

The  storage  of  rain  water  is  often  a  problem.  In  Venice  the  system 
is  good,  e.g.,  the  soil  is  excavated,  and  the  reservoir  thus  formed  is 
lined  with  brick  and  puddled  clay.  In  the  centre  of  this  a  brick  well 
is  built,  with  openings  in  the  sides  towards  the  bottom  of  the  shaft. 
The  remaining  part  of  the  reservoir  is  filled  with  sand,  into  which  the 
rain  water  first  flows.  In  other  countries  there  are  underground  tanks 
(Buenos  Aires),  stone  vaults  (Jerusalem),  or  large  galvanized  vats  on 
pillars  (Demerara  and  South  Africa).  Probably  the  best  is  a  tank  of 
galvanized  iron  or  in  brick  and  cement,  raised  from  the  ground,  pro- 
tected bv  a  roof  and  made  mosquito  proof.  All  such,  whatever  their 
construction,  must  be  under  the  constant  observation  of  a  Medical 
Officer  of  Health  to  control  fly  breeding,  &c. 

When  preparing  storage  tanks  the  longest  duration  of  the  dry 
season  must  be  known  with  the  accurate  rain  returns  and  the  amount 
of  water  required  daily.  The  average  during  twenty  years,  less  one- 
third,  is  about  the  rainfall  in  the  driest  year,  and  plus  one-third  in  the 
wettest  year. 

Onlv  a  little  more  than  one-half  of  the  rainfall  should  be  considered 
available  for  storage. 

First  washings  from  the  roof  should  be  rejected.  This  should  be 
by  a  small  receiving  tank  with  a  float  and  plunger  which,  when  the 
tank  is  full,  diverts  the  flow  into  the  storage  tank.  A  simple  method 
is  to  have  the  elbow  of  the  tank  supply  pipe  half-way  between  the 
roof  and  the  waste  gully  at  the  bottom.  When  the  rain  has  flushed 
the  roof,  plug  the  bottom  of  the  pipe,  the  water  then  rises  up  to  the 
elbow,  when  it  passes  down  into  the  tank.  Some  suggest  that  it  is 
always  better  to  pass  the  water  through  a  sand  filter  before  running  it 
into  the  storage  tank. 

All  pipes  should  be  protected  by  mosquito  copper  gauze. 

To  ascertain  the  dimensions  of  supply  pipes  needed  and  the  possible 
discharge  of  cubic  feet  in  a  given  time  through  a  given  pipe  is  often 
troublesome.     The  following  formula  will  be  a  guide  :  — 

If  water  with  a  head  of  H  feet  flows  through  L  feet  of  pipe  D  inches 
in  diameter,  the  discharge  W  will  be  in  cubic  feet  per  minute  :  — 

W,  =  472      /H    X   D'      hence  D  =  -538 -^    /JI^^ 
^'  L  '^  H 


WATER  547 

Surface  Water. 

We  have  stated  that  rain  water  flows  in  part  over  the  surface  of 
the  ground  into  natural  drainage  channels,  such  as  rivers  and  lakes. 
The  water  becomes  polluted  according  to  the  media  through  which  it 
passes. 

Lakes.  These  when  natural  or  artificial  form  the  purest  supply 
Avhen    containing   upland    waters.     Their   purity    is    the    result    of  :  — 

(i)  The  action  of  light,  destroying  surface  bacteria. 

(2)  The   subsidence  of  suspended   matters   entangling  bacteria. 

(3)  The    draining    of    underground    waters    which     have    already 

undergone   filtration    discharge    into   it. 

(4)  Its  free  oxidation. 

Alg^e  are  apt  tO'  form  in  all  standing  waters  and  should  be  removed 
by  screening  and  filtration.  It  is  better  to  store  underground  w^ater 
in  covered  reservoirs,  12  feet  deep  at  least,  witli  perpendicular  sides 
to  diminish  the  growth  of  alga^  when  this  is  troublesome.  Copper 
sulphate  can  be  added  also  in  the  strength  of  i   in   1,000,000. 

The  catchment  area  should  be  cuUi^'ated  and  be  as  free  as  possible 
from  dwellings  of  man  or  animals. 

Open  conduits  for  water  conveyance  should  be  immediately 
condemned. 

There  should  not  be  anv  peat  in  the  catchment  area,  for  not  only 
does  it  make  the  water  brackish  but  it  is  particularly  solvent  of  lead. 
If  the  presence  of  peat  cannot  be  avoided,  add  lime  to  the  water. 

Rivers.  Tropical  rivers  are  usually  of  greater  volume  and  are 
less  polluted  than  rivers  in  luirope,  hence  the  water  is  purer. 

The  fouling  of  the  water  by  dead  bodies  in  India  and  Africa  is 
becoming  a  thing  of  the  past. 

The  purity  of  these  waters  is  due  to  :  — 

(i)  The  great  dilution  of  any  pollution  that  reaches  them. 

(2)  The  great  volumes  of  filtered  water  that  reach  them. 

(3)  The  gradual   subsidence  of  organic  matter  to  the  bottom  and 

sides  where   it  undergoes  disintegration. 

(4)  The    oxidation    and    bactericidal    influence    of    sun    and    light. 

There   is   no   river   long  enough   in    the   United    Kingdom    to 
become  pure   by   oxidation    alone. 
The   water   from    small    shallow    rivers    is   always    dangerous   and 
should  be  avoided.     In  any  case  a  pipe  to  draw   river  water  should 
have  its  intake  as  near  to  the  middle  of  the  bed  of  the  river  as  possible 
and  above  any  villages  that  may  be  on  or  near  its  banks. 
The  water  should  always  be  boiled  and  filtered. 
Tanks  and  Ponds.     Water  from  surface  drainage  is  often  directed 
into  tanks  and  ponds  as  is  the  case  at  Calcutta,  but  they  are  ahvays 


548  TROPICAL    HYGIENE,    SANITATION,    ETC. 

subjected  to  much  pollution.  They  should  not  be  encouraged 
especially  amongst  the  native  peoples  of  a  country.  They  form  a 
good  growing  ground  for  all  kinds  of  parasites,  worms,  cyclops,, 
cholera  and  typhoid  bacillus,   mosquito  larvae,  &c.,  &c. 

Subterranean  Water. 

When  rain  water  falls  upon  permeable  soil  much  of  it  percolates 
through  the  first  impermeable  stratum,  the  depth  of  uhicli  may  vary 
much.  The  water  flows  on  the  surface  of  this  layer  in  the  direction 
of  its  fall  and  may  :  — 

(i)  Become  collected  in  the  indentations  of  its  surface  and  form 
shallow  wells, 

(2)  Form  a  reservoir  at  the  foot  of  the  fall, 

(3)  Find  a  place  where  the  impermeable  layer  comes  to  the  surface 

when  the  water  passes  beneath  it,  forming  deep  reservoirs 
of  water,  deep  springs,  constant  or  intermittent  or  when 
tapped  deep  wells  are  formed.  This  deep  water  may  also 
pass  into  a  river,  lake,  or  into  the  sea,  its  movement  being 
fairly  constant  but  slow.  The  level  of  this  underground  water 
varies  much  according  to  the  rainfall,  adjacent  springs,  river 
level,  &c. 

Subterranean  water  is  then  classified  according  to  its  relation  tO' 
the  first  impermeable  stratum  thus  :  — 

{A)  Ground   Water  above  the  impermeable  layer  forming  :  — 
(i)  Shallow  wells, 
(2)  Surface  springs. 

(jB)  Deep-seated  TTV/ier  beneath  the  impermeable  layer  forming:  — 
(i)  Deep  wells. 

(2)  Nearly  all  springs, 

(3)  Artesian  wells;  in  these  the  water  must  be  under  sufficient 
hydrostatic  pressure,  to  force  itself  to  the  surface  when  the 
well  is  bored. 

Shallow  Wells  and  Springs. 

The  depth  varies  from  2  to  50  feet  according  to  the  depth  of  the 
upper  impervious  stratum  and  the  depth  of  the  water  lying  upon  it. 

The  area  drained  and  affected  by  pumping  from  it  varies  according 
to  the  nature  and  lay  of  the  surrounding  soil,  but  it  may  be  from 
20  to  200  times  the  area  of  the  depression. 

The  water  mav  be  pure  while  the  drainage  area  is  free  from- 
contamination  as  was  the  case  in  the  South  African  War  before  men 
and  horses  were  picketed  upon  it,  and  as  at  Maidstone  before  the 
hop-pickers  squatted  upon  it,  and  as  in  certain  districts  of  India  prior 
to  their  occupation  by  pilgrims. 


WATER 


549 


As  the  water  percolates  tlirough  the  soil  it  becomes  charg-ed  with 
carbon  dioxide  from  the  air  interstices  of  the  soil,  after  which  it  may 
dissolve  out  lime,  mineral  salts  and  organic  matter.  The  soil  tends 
to  filter  and  remove  this  while  the  oxygen  present  in  the  soil  may 
oxidize  it  with  the  formation  of  nitrates. 

The  water  may  be  contaminated  by  :  Cesspools,  privies,  manure 
heaps,  sullage  water,  stables,  burial  grounds,  latrines,  and  as  the 
result  of  men  and  animals  residing  on  the  area.     The  contamination 


Well  with  hath  and  washhouse  on  one  side.  These  are  covered  with  old 
galvanized  iron,  old  rail,  &c.  Tubs  where  horses  and  cattle  stand  and  drink. 
The  drainage  runs  back  into  the  well. 

mav  not  be  obvious  until  the  rains  have  washed  the  filth  into  the 
water  or  until  the  water  has  risen  in  level  until  it  reaches  the  filth, 
or  carries  water  with  the  pollution  over  eminences  of  the  impervious 
layer  contaminating  the  wells  and  springs  beyond. 

In  India  and  China  infected  natives  often  wash  themselves  neai 
to  a  well  or  spring,  so  tliat  the  ablution  water  will  drain  back  again 
into  the  well  or  spring  in   a  polluted  condition. 

A  native  will  bathe  thrice  daily,  yet  he  will  drink  water  unhesi- 
tatingly which  is  obviously  filthy. 


550 


TROPICAL    HYGIENE,    SANITATION,    ETC. 


A    large    proportion    of   typhoid    epidemics    is    due    to    the    use   of 
shallow    wells. 

Any  well  should  have  the  brick'-work  run  up  to  a  height  of  several 


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feet  above  the  surface  of  the  ground,  with  a  dome-shaped  cover  over 
;!:he  top,  well  cemented,  and  the  sides  cemented  down  to  the  impervious 
layer  or  to  below  the  water  level.  Around  the  well  for  a  distance  of 
12  feet  should  be  concreted,  sloping  ofT  from  the  well  so  that  drainage 
away  from  the  well  will  be  facilitated. 


WATER  551 

A  tube  or  Abyssinian  well  for  shallow  water  in  the  tropics  is  often 
a  temporary  necessity.  The  water  is  usually  within  25  feet  of  the 
surface.     This  tube-well  cannot  penetrate  rock. 

It  has  the  adyantage  that  the  tube,  ij-  to  4  inches  in  diameter,  may 
be  driyen  beneath  the  upper  impervious  la\'er  and  so  reach  deep  water. 
A  pump  is  attached  to  the  upper  length  of  piping  which  is  embedded 
in  cement  at  the  top.  Water  is  yielded  according  to  the  diameter  of 
the  pipe,  the  supply  being  constant.     Thus:  — 

ij-inch  pipe  will  yield  150  -  600  gallons  of  water  per  hour 

3  ))  .)  300  -  1,200  „ 

4  »  „        1,200  -  4,400  „  „ 

The  Sulliyan's  diamond  drill  produces  a  form  of  bore  well  that 
can  penetrate  rock  and  produce  large  supplies  of  water.  The  tube 
can  be  sunk  at  an  average  rate  of  28  feet  in  twenty-four  hours. 

Such  a  bore-hole  will  produce  much  more  water  than  a  well  of 
6  feet  diameter.  The  Chinese  are  credited  w'ith  boring  by  means  of 
a  rope  and  chisel  down  to  a  depth  of  1,000  feet  in  the  olden  days. 

An  ordinary  well  can  be  converted  into  a  tube-well  by  inserting 
a  tube  and  filling  the  well  with  sand  and  pebbles. 

The  pump  can  be  erected  some  distance  away  from  the  well. 

Deep  Wells. 

This  water  supply  is  derived  from  a  wide  catchment  area  or  some- 
times from  distant  hills.  As  a  rule  the  filtration  has  removed  all 
organic  matter  but  the  surface  and  surroundings  of  the  well  must  be 
protected. 

Artesian  (from  Artois  in  France)  wells  are  artificial  springs. 

The  water  is  pure  if  it  does  not  contain  an  excess  of  mineral 
matter.  A  great  advantage  of  this  kind  is  the  depth  to  which  they 
can  be  sunk,  1,500  to  4,000  feet.  In  this  way  cholera  can  be  avoided 
as  at  Pondicherry. 

Water  can  be  found  in  districts  formerly  considered  waterless, 
by  these  means  as  at  Queensland,  and  pure  water  has  been  obtained 
on  the  sea  shore  as  at  Java. 

The  water  from  these  wells  is  sometimes  brackish  though  it  is  pure 
and  its  temperature  sometimes  raised. 

WATER— TRANSPORT. 

House  to  house  distribution  by  means  of  pipes  is  a  rare  luxury  in 
the  tropics.  A  supply  in  each  street  is  not  as  common  as  it  should 
be.  In  India  the  Mahommedan  water-carrier  serves  each  house  from 
his  mashak  of  goat  or  calf  skin  by  means  of  which  he  can  generally 
infect  water  that   is  pure  prior  to   its  being  put    into   the   receptacle. 

35 


552  TROPICAL    HYGIENE,    SANITATION,    ETC. 

The  metal  vessels  used  by  the  Hindus  for  water  transport  are  certainly 
an  improvement  on  the  mashak,  especially  as  the  metal  tends  to 
sterilize  the  water.     They  can  also  be  better  cleaned. 

A  pipe  supply  from  a  reservoir  is  preferable.  For  a  reservoir  a 
valley  could  have  a  concrete  or  clay  puddle  and  a  dressed  stone, 
water-tight  division  thrown  across  it.  Or  an  excavation  could  be 
made.     An  overflow  weir  and  an  emptying  pipe  are  essential. 

The  points  to  watch  before  construction  are  :  Suitability  of  site, 
sufficiency  of  water  supply,  amount  in  gallons  to  be  supplied  per  head 
per  diem,  size  of  reservoir,  number  of  days'  supply  to  be  stored,  the 
primary  use  of  the  reservoir,  i.e.,  is  it  to  be  a  quiescent  settling  basin 
or  preferably  a  continuous-flow  settling  basin  ? 

Conveyance  by  means  of  pipes,  galvanized  and  lined  with  pitch 
or  other  anticorrosive  substance  is  to  be  preferred  to  the  open 
channels. 

Airi  vents  will  be  needed  at  the  summit,  debris  sluices  below  and 
cleansing  sections  at   intervals. 

Iron  pipes  become  diminished   in   diameter   owing  to  :  — 

(i)  Incrustations  from  oxidation  w^hich  can  only  be  prevented  by 

iseveral  more  layers  of  pitch  on  the  inner  side. 
(2)  Ferruginous  slime  in  acid  waters  formed  by  germs  and  young 
chlamydothrix  which  become  attached  to  and  grow  rapidly 
upon  the  inner  linings.  Alkaline  waters  and  those  containing 
carbon  dioxide  are  free  from  them.  The  Clarke  softening 
process  is  necessary,  followed  by  efficient  filtration. 
(3)  Debris  in  the  irregularities  of  the  water-main  which  can  be 
corrected  bv  brushing  and  rapid  sluicing. 

WATER— PATHOLOGY. 

A  pure  sojt  water  acts  upon  zinc,  e.g.,  on  galvanized  kettles,  &c., 
as  a  solvent  so  as  to  make  the  water  injurious  to  health.  Lead  is  also 
dissolved  by  soft  w^aters.     Such  water  should  be  hardened  with  lime. 

There  is  no  evidence  that  hard  water  is  injurious.  It  does  not 
bring  on  old  age  neither  does  it  cause  gout,   rheumatism,  &c. 

Waters  that  are  peaty  owing  to  their  acidity  often  dissolve  lead 
from  the  service  pipes  as  lead  carbonate.  On  standing  or  boiling 
the  lead  carbonate  is  thrown  out  with  calcium  carbonate. 

Vegetable  matter  in  solution  or  suspension,  from  any  source,  may, 
if  in  sufficiency,   cause  diarrhoea. 

Animal  matter  in  solution  or  suspension  is  always  dangerous  to 
health,  causing  reduction  in  general  bodily  resistance,  acute 
alimentary  disturbance,  epidemic  diarrhoea,  dysentery,  cholera,  para- 
sitic diseases  and  diseases  of  the  typhoid  group. 


If  ATE  R 


553 


Mineral  or  clicinical  constituents  m:iv  cause  epidemic  i^oitre, 
plumbism,   lead  colic,  urinary  calculi  (  ?),  cretinism,  &c. 

Brackish  water  often  causes  diarrlicea  in  those  newlv  coming-  into 
the  district. 

Excess  of  alkaline  carbonates  causes  constipation. 

A  large  number  of  non-pathogenic  bacteria  will  cause  muco- 
enteritis. 

Suspended  clay,  mica,  quantities  of  sodium,  calcium  and  mag- 
nesium salts  will  cause  intestinal  disorders. 

Putrefying  carcases  of  horses,  cattle  and  humans  will  lead  to 
diarrhoea  and  dysentery. 

Dysentery  is  nearly  always  due  to  a  contamination  bv  excremen- 
titious  matter,  both  bacillary  and  amoebic,  but  urine  is  another  factor 
in  typhoid  cases. 

The  ova  and  embryos  of  entozoa  and  leeches  pass  to  the  body  in 
impure  water. 

WATER— CONTROL. 

A  suitable  qualified  Medical  Ofificer  must  control  the  Avater  supplies 
on  behalf  of  the  Company  or  Sanitary  Authority. 
His  supervision  must  include  :  — 

A  knowledge  of  the  "  life-history  "  of  the  water. 
The    systematic    inspection    of    the    source,    gathering   ground, 
reservoirs,    means    of   conveyance    and    the    control    of    the 
storage  tanks,  filter  beds,  &c. 
The  physical,    chemical   and   bacterial   examination   of   samples 
from  various  points  of  the  supply. 

WATER— SOURCE  OF  CONTAMINATION. 

Elementary  tests  are  very  useful  to  ascertain  the  source  of  con- 
tamination and  often  of  its  nature.  This  preliminarv  being  necessarv 
previous  to  the  adoption  of  purifying  measures. 

Where  apparatus  and  chemical  reagents  are  not  to  hand  obvious 
contaminations  should  be  dealt  with  at  once  without  awaiting  analysis. 

To  ascertain  source  of  contamination  test  by  putting  chemicals  in 
the  water  and  searching  for  them  later  elsewhere,  e.g., 

(i)  Sodium  chloride  is  traced  by  the  silver  nitrate  test. 

(2)  Lithium  chloride  is  traced  by  the  evaporation  of  quantities  of 

the  water,   the  residue  gives  a  crimson   colour.     One  part    in 
one  million  can  be  recognized.     The  test  is  expensive. 

(3)  Ammonium   chloride  can   be   traced   in  one   million   gallons  of 

water  if  seven  pounds  of  the  salt  are  used. 


554  TROPICAL    HYGIENE,    SANITATION,     ETC. 

(4)  Fluorescence  or  resorcin  thallin  is  traced  by  its  colour,  one  in 
one  hundred  million  parts  of  water.  Six  ounces  of  the  sub- 
stance should  be  dissolved  and  distributed  on  the  refuse 
suspected  of  carrying  the  contamination.  This  will  show 
itself  in  the  drains,  wells,  &c.,  in  a  short  time  if  such  con- 
taminated water  drains  into  them.  Should  the  water  happen 
to  be  acid  there  will  be  no  colour,  but  one  must  add  some 
caustic  potash  when  making  the  solution.  Pour  plenty  of 
water  on  the  refuse  heap  after  the  fluorescence  has  been  dis- 
tributed. Bromine  will  remove  the  colour  when  the  test  is 
finished. 

One  must  always  exclude  the  presence  of  the  testing  salts  in  the 
water  before  making  the  test. 

WATER— PURIFICATION. 

The  purification  of  all  tropical  waters  is  essential. 

For  small  c{uantities  the  apparatus  must  be  small  and  the  process 
simple,   rapid  and  efficacious. 

For  large  quantities  there  will  be  a  permanent  apparatus  and  the 
process  will  be  elaborate,   slow  and  also  efficacious. 

The  ways  and  means  will  be  also  controlled  by  the  peculiar  con- 
tamination to  be  removed  as  alg^e,  lead,  iron,  &c. 

There  are  many  methods,  selected  according  to  each  particular 
case,  two  or  more  of  which  may  be  used  for  the  same  water. 

For  the  personal  use  of  travellers  the  best  means  are  :  — 

(i)  Boiling. 

(2)  Berkefeld's  pump  or  ordinary  filter. 

(3)  Chemical    soloids    of   calcium    hvpochloride,    &c.,    such    as   are 

supplied  by  B.  W.  and  Co. 

Such  methods  can  also  be  used  for  larger  quantities. 

The  principal  means  in  general  for  water  purification  are 
mechanical,  chemical  and  filtering  efTected  by  means  of  storage, 
precipitation,   chemicals,   heat,   electricity,   filtration  and  oxidation. 

(1)  Storage. 

This  does  not  sterilize  water. 

In  water  stored  for  one  week,  99  per  cent,  of  cholera  organisms 
will  be  killed.     In  that  stored  for  three  weeks  none  remained. 

In  water  stored  for  five  to  eight  weeks  the  typhoid  bacillus  will 
die,  hence  storage  is  a  great  help  towards  sterilization. 

Storage  for  one  month  with  a  series  of  reservoirs  and  a  continuous 
flow  to  avoid  the  development  of  algas,  is  said  to  be  almost  an  absolute 
protection  against  epidemic  infections.  Not  only  are  the  bacteria 
enormouslv   reduced   but   other   unpalatable   conditions   and    injurious 


JVATER  555 

ingredients  as  suspended  matter,  ammoniacal  nitrogen  and  also  hard- 
ness are  removed. 

By  storage  the  bacteria  become  entangled  in  the  precipitate  and 
are  carried  down. 

(2)   Precipitation. 

To  assist  in  this  process  various  substances  are  added  such  as  :  — 

Vegetable  Juices  containing  tannin,  e.g.,  tea,  kino,  &c.,  which 
coagulate  the  organic  matter.  Cold  tea  is  therefore  an  excellent  drink 
for  travellers  because  :  — 

It  ensures  the  water  having  been  boiled. 

The   tea   strains   suspended   matters. 

The  tannin  coagulates  and  precipitates  organic  matter. 

Chemicals  are  also  used,  as  alum  6  grains  (o"4  grm.)  per  gallon 
(4"5  litres)  followed  by  5  grains  (0*3  grm.)  of  precipitated  lime  per 
gallon.  Alum  also  decreases  the  number  of  micro-organisms  present 
but  not  those  of  the  typhoid  and  cholera  groups. 

Chemicals. 

Chemicals  are  used  for  softening  and  purifying  water,  but  all  such 
meithods  should  be  followed  by  filtering. 

The  alum,  lime  and  soda  compound  method  of  Maignen's  process 
(anti-calcaire)  is  well  known.  All  similar  processes  contain  lime 
which  combines  with  the  carbon  dioxide  and  forms  a  deposit  of 
calcium  carbonate  carrying  down  with  it  the  organic  matter. 

Clarke's  process  for  softening  water  is  popular.  Use  freshly 
burned  lime,  6  pounds  (2"5  k.)  per  100,000  gallons  of  water,  for 
each  degree  of  hardness. 

The  Porter-Clarke  process  is  a  modification  of  this.  The  former 
slow  process  is  hastened  by  filtration  under  pressure  through  cloth. 

Chloride  of  lime  is  also  used,  i  to  6  parts  of  available  chloride  per 
million  is  sufficient.  Filtration  and  passing  the  water  through  carbon 
will  remove  the  excess  of  chlorine. 

If  the  water  is  free  from  suspended  matter,  calcium  hypochlorite 
is  useful. 

Use  three  parts  per  million  =  one  part  of  available  chlorine,  and 
remove  the  excess  a  little  later  with  sodium  bisulphate  (Thresh). 
This  more  or  less  sterilizes  such  water  at  a  cost  of  id.  per  25,000 
gallons.     The    onlv    apparatus    required    is    that    of    ordinary    tanks. 

Six  hundred  American  cities  now  use  this  process. 

In  smaller  quantities  of  water  use  a  teacupful  of  calcium  hypo- 
chlorite and  three  teacupfuls  of  water.  Of  this  mixture  use  one 
teaspoonful  to  two  gallons  (nine  litres)  of  water.  Allow  it  to  rest  for 
fifteen  minutes. 


556  TROPICAL    HYGIENE,    SANITATION,    ETC. 

To  those  accompanying  expeditions,  &c.,  the  following  facts  by 
Dr.  Thresh  may  be  useful  :  — 

(i)  Obtain  a  supply  of  high  quality  chlorinated  lime  in  quarter- 
pound  hermetically  sealed  tins.  (From  the  United  Alkali  Co. 
Liverpool.) 

(2)  Obtain  a  corresponding  number  of  half-pound  tins  of  sodium 

hyposulphite.  This  salt,  known  more  commonly  as  hypo- 
sulphite of  soda  used  in  photography,  is  nearly  tasteless  and 
combines  with  all  the  available  chlorine  in  about  half  its 
weight  of  chlorinated  lime.  From  these  the  following  stock 
can  be  prepared. 

(3)  Add  the  contents  of  a  tin  of  No.   i   to  a  gallon  of  water  and 

shake  until  uniformly  mixed. 

(4)  Add   one   packet   of   thiosulphite   to   one   gallon    of   water   and 

shake  until  dissolved. 

One  gallon  of  solution  No.  3  will  sterilize  8,000  gallons  of  anv 
ordinary  clear  well  or  river  water  in  iifteen  minutes,  and  if  at  the 
expiration  of  that  time  the  one  gallon  of  thiosulphite  solution  No.  4 
be  added  to  the  water  any  excess  of  chlorine  will  be  eliminated.  One 
fluid  ounce  of  No.  3  is  sufficient  for  50  gallons  of  water.  In  no  case 
should  less  than  i  part  of  chlorine  be  added  to  1,000,000  parts  of 
water,  and  if  the  water  is  known  to  be  foul,  2,  3,  or  even  more  parts 
should  be  used. 

This  process  can  be  depended  upon  to  remove  any  typhoid  or 
cholera  organisms  which  may  be  present  in  the  water,  and  the  same 
applies  to  the  species  of  bacilli  which  are  the  probable  cause  of 
dysentery. 

Iron  is  removed  by  adding  lime  and  then  filtering  through  sand. 

For  Anderson's  process  iron  is  required.  The  water  passes 
through  revolving  drums  and  is  subjected  to  showers  of  metallic  iron. 
The  excess  of  the  latter  is  removed  by  oxidation,  precipitation  and 
filtration.     It  is  not  applicable  to  peaty  waters. 

Ozone  is  now  becoming  better  known.  The  water  falls  from  a 
tower  through  rough  stones  and  ozone,  which  latter  is  admitted  at  the 
bottom  of  the  tower.  The  ozone  rises,  meets  the  descending  water, 
and  sterilizes  it  as  it  descends.  The  ozone  is  prepared  by  passing 
dried  air  through  ozonizers  supplied  with  electricity. 

These  machines  are  expensive,  but  the  method  is  very  efficacious. 

Each  ozonizer  of  one  horse  power  and  of  S,ooo  volts  A'ields  \x$  ^<'' 
27  grams  of  ozone  in  twenty-four  hours  and  sterilizes  26,400  to  52,800 
gallons  per  diem.  The  excess  of  ozone  is  lost  by  passing  the  water 
over  cascades  at  the  bottom  of  the  tower. 

Water  containing  iron  would  still  require  filtering. 


WATER  557 

A  portable  petroleum-driven  motcr  and  apparatus  is  on  the  market 
which  is  capable  of  sterilizing  400  to  600  gallons  per  h(jur  equivalent 
to  3  cubic  metres.     This  is  very  suitable  for  troops. 
Like  most  processes  it  has  its  disadvantages,   e.g., 
(i)  The  water  often  accjuires  a  disagreeable  taste. 

(2)  Nitrous  acids  are  often  produced  along  with  the  ozones. 

(3)  The  initial  cost   is  considerable. 

(4)  Skilled  supervision  is  necessary. 

Permanganate  of  potash,  i  in  4,000  or  4  ounces  (113  grm.)  for  an 
ordinary  well  is  sufficient.     It  is  useful  for  cholera-infected  wells. 

The  water  should   remain   pink   for   half-an-hour  afterwards. 

Alum  will  remove  the  excess  of  colour.  It  will  also  remove  the 
odour  of  offensive-smelling  waters.  For  smaller  quantities,  boil  the 
water  and  then  add  the  permanganate  until  a  pink  tinge  remains  for 
thirty  minutes. 

The  Compound  Tablet  is  now  in  use  and  has  proved  its  worth. 

The  ing-redients  of  these  tablets  varv  but  that  of  Vaillard  is  a 
good  preparation  :  — 

(i)  Blue  tablet  contains:  Pot.  iodide,  o'l  grm.,  sod.  iodide, 
o"oi56  grm.,  and  of  methylene  blue,  a  sufficiency. 

(2)  Red  tablet  contains:  Tartaric  acid,  o-ioo  grm.,  fuchsin,  a 
sufficiency. 

(3)  White  tablet  contains:   Sodium  hyposulphite,  o-ii6  grm. 

To  one  litre  of  water  add  one  tablet  of  Nos.  i  and  2.  As  a  result 
of  this  o-o6  o-rm.  of  free  iodine  is  liberated  which  sterilizes  the  water 
in  fifteen  minutes.  Then  add  a  white  tablet  which  neutralizes  the 
free  iodine.     The  resulting  water  is  colourless  and  odourless. 

Ova  and  probably  parasites  are   not  destroyed   by   it. 

Liquid  chlorine  has  been   used  for  the  troops  in  the  field. 

I '50  grm.  of  chlorine  for  50  gallons  of  water. 

Then    sodium    sulphite,    36    grm.    are    added    to    neutralize    the 

chlorine. 

The  gas  disappears  spontaneously  in  twenty-four  hours,  after  which 
period  no  sodium  sulphite  is  required.  The  cost  is  low,  only  id.  per 
500  gallons. 

Copper  sulphate  is  used,  i  in  1,000,000  to  :  — 

(i)  Clear  rivers  and  lakes  of  algas. 

(2)  Kill  mosquito  larvae  in  water  tanks. 

(3)  To  rid  waters  of  odours  arising  from  micro-organisms  and  alg^e. 
F'ishes  are  killed  by  it. 

Chalk,  finely  ground,  is  used,  one  grain  (o'o6  grm.)  per  gallon. 
It    prevents    plumbo-solvency    where    this    may    take    place.      THp 
water  must  then  be  filtered  and  lime  water  added. 


558  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Peaty  waters  containing  acids  from  moorlands  cause  plumbo- 
solvency. 

Lacmoid  Avill  become  reddenea  in  such  waters,  thus  indicating 
their  presence.     jNIanganese  oxide  on  the  fiUer  beds  is  etMcacious. 

Thermal. 

Boiling  destroys  all  living  organisms  and  reduces  hardness  but  the 
difficulty  is  with  cooling  afterwards.  Earthernware  vessels  placed  in 
an  air  current  are  useful  for  this  purpose.  The  flat  taste  can  be 
removed  b_v  oxidation.  Weak  tea  is  advisable  for  travellers  for 
reasons  previousl}'  described. 

Heat  has  been  used  to  sterilize  water  under  pressure  so  that  no 
gases  are  lost;  the  cool  water  passing  in  being  used  to  cool  the  water 
passing  out,  but  the  process  is  expensive  when  used  on  a  large  scale. 
The  pipes  are  readily  occluded  when  the  Avater  is  hard.  A  number 
of  inventions  are  on  the  market  for  this  purpose. 

The  Maiche  Automatic  Sterilizer  is  serviceable.  It  cost  (pre-war) 
;^56,  uses  5  gallons  of  kerosene  weekly,  cost  of  maintenance  is  Qd. 
daily,  and  it  produces  800  to  1,000  gallons  of  sterilized  water  per  diem. 

The  oil  lamp  is  filled  twice  daily,  otherwise  it  is  left  to  work 
automatically. 

Steam  pipes  conveying  steam  to  water  tanks  will  sterilize  the  water, 
after  which  the  water  can  be  left  to  cool. 

Distillation  is  of  universal  application  and  is  essential  for  all 
important  ships  as  sea  water  can  be  utilized  bv  these  means. 

The  flat  taste  is  removed  by  the  water  falling  through  a  sieve  or 
by  charging  it  with  carbon  dioxide  under  pressure. 

Electrical. 

Ultra-violet  rays,  generated  by  a  quartz  mercury  vapour  lamp,  are 
now  used  as  sterilizing  agents.  Courmont  and  Nogier  found  that 
when  a  Kromayer  lamp  was  immersed  in  water  containing  1,000,000 
bacteria  and  100,000  B.  coli  per  c.c.  that  it  was  completelv  sterilized 
in  one  minute.  Previous  filtration  is  almost  obligatory  as  suspended 
and  colloidal  matter  nullifies  the  action. 

Thresh  and  Beale  found  that  a  small  Cooper  Hewitt  quartz  lamp 
would  purify  50  to  200  gallons  per  hour.  At  Luneville  in  France, 
there  was  an  installation  a\  ith  a  ten-lamp  canal  which  has  practicallv 
banished  typhoid  from  the  city. 

The  energy  required  is  from  50  to  130  units  per  million  gallons 
of  water.     A  portable  apparatus  is  now  on  the  market. 

Filtration. 
A.  Domestic  Filtration. 

The  Pasteur-Chamberland  porcelain  filter  and  the  Rerkefeld  filter 
of  diatomaceous  earth  are  the  best. 


WATER  559 

Unfortunately  the  mud  and  slime  of  tropical  rivers  rapidly  stops 
the  action  of  the  best  filters  so  that  constant  cleansing  is  necessary. 
They  should  be  scrubbed  and  boiled  once  weekly. 

The  candles  are  very  frail  and  readily  break.  A  large  stock  of 
them  must  be  kept. 

Other  filters  are  not  considered  to  be  as  efficacious. 

A Domestic  Filtration. 

A  cemented  reservoir  is  prepared,  5  to  6  feet  deep  (i  to  2  metres) 
and  made  up  in  layers  of  broken  stones  and  pebbles,  coarse  gravel, 
coarse  sand  and  fine  sand.  Water  should  not  flow  through  the  filter 
at  more  than  4  inches  (100  mm.)  an  hour,  and  not  more  than  200,000 
gallons  per  acre  per  hour.  The  finer  the  sand  and  the  thicker  the 
laver  the  more  efficacious  it  becomes. 

A  sand  filter  affords  :  — 

(i)  Mechanical  obstruction  to  coarse  particles. 

(2)  Oxidation   of  organic   matter. 

(3)  Nitrification  by  micro-organisms  on  the  surface   layer. 

(4)  Removal  of  turbidity. 

(5)  Reduction  of  hardness  and  removal  of  iron. 

There  is  a  slimy  layer  on  the  surface  of  all  large  filters  containing 
a  gelatinous  mass  of  intercepted  bacilli,  streptococci,  micrococci,  alga^ 
and  other  bodies,  while  immediately  below  this  film  is  a  layer  of 
nitrifving  organisms.  By  this  film  the  pathogenic  micro-organisms 
are  intercepted  and  destroyed,  the  organic  matter  broken  up  into  car- 
bonic acid  and  ammonia,  the  ammonia  being  converted  into  nitrous 
and  nitric  acids  bv  the  nitrifying  organisms.  When  the  slimy  layer 
becomes  so  thick  that  it  prevents  the  water  from  passing  through, 
half  an  inch  should  be  scraped  off  the  surface  and  the  under  layer 
distributed  by  means  of  a  rake.  When  the  sand  layer  is  only  one 
inch  thick,  the  bed  should  be  made  up  again.  The  first  water  which 
passes  through  before  the  slimy  layer  is  formed  (during  the  first 
twentv-four  hours)  may  be   impure  and   should  be   rejected. 

Allow  three  feet  (one  metre)  of  water  to  stand  in  the  filter  for 
twenty-four  hours. 

There  should  not  be  more  than  100  micro-organisms  per  c.c.  in 
the  filtered  water.  98  to  99  per  cent,  of  those  in  the  original  water 
should  have  been  removed  by  the  filter. 

Too  much  exposure  to  the  sun  favours  the  growth  of  algc-e,  hence 
filter  beds  should  be  covered  over.  By  this  means  dust  and  mosquito 
breeding  will  be  avoided. 

Water  should  pass  through  a  settling  or  storage  tank  before  and 
after  filtration.  The  processes  of  filtration  and  sedimentation  should 
alwavs  be  combined. 


5Co 


TROPICAL    HYGIENE,    SANITATION,    ETC. 


Mechanical  sand  fillers  are  as  the  above  but  smaller  and  con- 
structed of  iron  or  steel,  with  pressure  to  hasten  the  process.  Sulphate 
of  alumina.  2  gr.  per  gallon  (o'i2  grm.  per  4*5  litres)  is  added  to  form 
an  artificial  film  on  the  surface. 

The  pressure  is  by  compressed  air,  the  pressure  being  reversed 
and  often  steam  applied  for  the  cleansing  process. 

The   rate   of   filtration    is  about   fifty   times   greater   than    the   slow 


L^WaEJt.5fI 


^S^N5i^Jii^EFt^€- 


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FINESAND    . 

2  F^   3 i':' 


a   CONCRETE      BASE     6f'    rjLTER     t   Jn 


Diagram    of    a    section   of    a 
sand  filter. 


GRAVEL 


WASTE   PIPE 
CONNECTING  WITH 
SEWER 


Diagram  of  a  mechanical  filler. 


sand  filter.  Such  filters  have  proved  useful  at  Alexandria  and  Mvsore, 
where  the  water  is  turbid.  They  are  largely  used  in  the  States  of 
America  where  the  river  water  is  heavily  charged  with  suspended 
matter. 

It  is  often  necessary  to  cleanse  washing  wafer  as  for  troops  in  the 
field.  The  following  method  as  practised  by  Norman  Goode  and 
Basil  Hughes  has  proved  useful  to  such  an  extent  that  the  same  water 
can  be  used  an  unlimited  number  of  times. 

The  soapy  water  runs  from  the  bath   house   into  a   mixing  tank. 


]]'ArER  561 

In  this  tank  slaked  lime  is  placed  and  the  whole  well  mixed. 
The  lime  throws  down  the  soap  as  insoluble  calcium  stearates. 
It  also  brings  down  all  the  dirt  and  impurities. 

The  effluent  flows  through  a  series  of  three  up-and-dcwn  settling 
tanks  connected  together,  the  scum  is  stopped  b}'  canvas  screens 
placed  vertically  reaching  two-thirds  of  the  distance  down  from  the 
top  and  up  from  the  bottom  alternately. 

All    the   calcium    stearates    settle    in    the    first    tAvo    tanks. 

The  third  tank  is  used  for  precipitating  the  lime  and  removing  the 
soapy  oils.  Washing  soda  is  run  into  this  tank  which  produces 
insoluble  calcium  carbonates  which  sink  to  the  bottom.  Consequently 
the  soapy  oils  separate  out,   float  and  are  collected  on  canvas. 

The  canvas  is  chang'ed  daily. 

The  water  then  flows  into  a  charcoal  filter,  six  feet  square  by 
eighteen  inches  deep  with  four  inches  of  charcoal  between  two  layers 
of  sacking  in  a  perforated  zinc  tank. 

It  passes  from  this  into  a  concreted  well. 

The  water  is  pumped  from  this  well  into  an  elevated  tank  for 
repeated  use. 

The  mixing  tank  is  cleaned  out  daily  and  the  sludge  is  buried. 

The  first  precipitating  tank  is  cleaned  out  every  third  dav. 

The  water  thus  treated  is  free  from  dirt,  soap,  lime,  soapy  oils  and 
readily  lathers  with  soap. 

4,000  gallons  pass  through  daily  and  2,000  men  use  the  same  water 
daily. 

Oxidation. 

The  "fishy"  waters  of  Mauritius  were  made  potable  bv  means 
of  a  special  oxidation  process.  The  water  was  run  over  perforated 
trays,  allowing  it  to  drop  4  to  6  feet,  finely  divided,  during  which 
time  the  water  became  almost  saturated  with  oxygen. 

Oxidation  is  also  carried  out  to  some  extent  during  intermittent 
filtration.     The  process  can  be  used  to  get  rid  of  iron. 

This  process  :  — 

(i)  Oxidizes  the  ferrous  compounds. 

(2)  Oxidizes  the  ferric  hydroxide,    in   both    instances   precipitating 

organic  matters. 

(3)  Facilitates  the  destruction  of  residual  organic  matter. 

(4)  Aerates  and  hence  makes  potable  certain   drinking  waters. 
All  water  should  be  passed  through  a  filter  afterwards. 
Boiled  and  distilled  water  could  be  aerated  in  this  way. 

Filterable  Viruses. 

This  term  is  applied  to  micro-organisms  so  small  that  they  will 
pass  through  an  ordinary  fiker  which  will  keep  back  ordinary 
bacteria. 


562  TROPICAL    HYGIENE,    SANITATION,    ETC. 

The  first  was  demonstrated  in  1892  b_Y  hvanowski,  the  mosaic 
disease  of  the  tobacco  plant. 

In  man  we  find  the  viruses  of  :  — 

YeUow  fever,  which  is  destroyed  at  53°  C.  in  ten  minutes. 

Dengue  fever,  Three  days  fever,  Pappataci  fever,  Molkiscum  con- 
tagiosum,  PohomyeHtis,  Measles,  Scarlatina,  Verruca  vulgaris, 
Trachoma,   Typhus,   which  is  destroyed  by  a  temperature  of  55°  C. 

Variola  and  Vaccinia  are  both  destroyed  at  58°  C.  in  fifteen 
minutes. 

In  nearly  every  case  the  immunity  produced  by  the  disease  is 
complete. 

Secondary  infections  may  give  rise  to  many  symptoms  which  may 
be  confused  with  the  true  symptoms  of  the  original  disease. 

It  should  be  remembered  that  filtration  of  water  will  not  aid  much 
in  the  prophylaxis  of  the  above  diseases. 

In  advising  as  to  water  purification,  all  the  facts  of  the  particular 
case  must  be  taken  into  consideration.  Thus  if  the  water  is  derived 
from  a  source  free  from  human  pollution  and  the  ingredients  to  be 
removed  are  suspended  particles,  colouring  matter  and  iron  in  solution, 
the  mechanical  filter  will  be  sufficient. 

But  if  the  water  is  or  may  be  polluted,  some  process  of  storage, 
sterilization,  and  slow  sand  filtration  are  necessary. 

Mechanical  filters  combined  with  storage  will  give  a  satisfactory 
water  supply  in  the  majoritv  of  instances,  but  so'me  waters  will  always 
require  an  adequate  sterilization  process  as  in  some  parts  of  India 
where  pilgrimages  are  common. 

For  important  notes  on  the  Bacteriology  of  Tropical  Waters,  see 
p.  640,  Section  IX,  Laboratory  Hints. 

FOOD. 

NUTRITION. 

The   essential   constituents  of   food   are  :  — 

(i)  Nitrogenous,  animal  and  vegetable  albuminoids  (proteins)  and 
gelatin. 

(2)  Fatty,  animal  and  vegetable  fats  and  oils. 

(3)  Carbohydrates,  starches  and  sugars. 

(4)  Salts,  organic  and  inorganic. 

(5)  \\^ater  and  vilamines. 

Nitrogenous  foods  are  necessary  for  growth,  maintenance,  repair, 
functional  activity  and  in  some  measure  the  production  of  heat  and 
force  for  the  body. 

Assimilation  of  excess  of  nitrogen,  in  the  absence  of  exercise,  leads 


Foon  563 

to  imperfect  oxidatiun  with  the  formation  of  urates  and  uric  acid 
followed  by  congestion  of  the  liver,  looseness  of  the  bowels,  slight 
pyrexia  and  general  debility. 

Deficiency  of  nitrogen  is  followed  by  anaemia,  wasting,  reduction 
of  energy  and  resistance. 

Gelatin  is  able  to  replace  the  circulatory  albumin  but  does  not 
form  tissue  albumin  or  repair  its  waste.  Its  nutritive  value  is  24  per 
cent,  that  of  albumin. 

Fats  and  carbohydrates  provide  material  for  oxidation  which  pro- 
cess produces  heat  and  force.  As  a  result  of  oxidation  carbon  dioxide 
and  water  are  formed  wdiich  in  turn  assist  in  nutrition  and  the  removal 
of  waste  material. 

Ingestion  of  excess  results  in  lessened  oxidation  of  nitrogenous 
matter  and  the  storage  of  fat  in  the  tissue. 

Deficiency  causes  increased  metabolism  of  circulating  albumin,, 
loss  of  w-eight  and  the  impairment  of  nutrition. 

Fatty  tissue  is  a  good  lubricant,  a  non-conductor  of  heat,  a  pro- 
tection for  the  deeper  structures,  and  affords  rotundity  for  the  bodv. 

An  excess  of  fatty  food  may  lead  to  inconveniences  as  in  obesity,, 
or  to  dangers  as  in  fatty  infiltration  of  the  heart. 

Carbohydrates  are  readily  assimilated  but  are  less  nutritive  than 
fats  by  40  per  cent. 

Salts  are  used  up  in  the  body  as  follows  :  — 

(i)  For  bone  formation,  e.g.,   lime,  potash,  soda  and  magnesia. 

(2)  The  nutrition  of  the  firmer  tissues,  e.g.,  potash. 

(3)  The   maintenance    of    the    fluid    tissues,    e.g.,    soda,    chlorides,. 

phosphates. 

(4)  The    maintenance    of    alkaline    fluids,    e.g.,    organic    acids    as- 

lactates,   tartrates,   citrates,  &c. 

(5)  To  increase  oxygen-carrying  capacity,   e.g.,   iron  salts. 
Vegetable  products  are  rich  in  potassium  salts  while  animal  foods 

are  poor  in  them. 

Water.  This  is  our  greatest  solvent  and  makes  up  two-thirds  of 
our  body  weight.     By  it  :  — 

(i)  Food  is  dis.solved  and  carried  to  the  (issues. 

(2)  Chemical  changes  are  made  possible. 

(3)  The  body  temperature  is  regulated. 

(4)  Waste  products  are  removed  and  excreted. 

Food-adjuncts  are  non-essential  foods  used  as  a  habit,  to  produce- 
variety,  stimulate  appetite  and  to  modify  taste,  e.g.,  alcoholic  liquors, 
volatile  or  essential  oils  and  aromatic  compounds  found  in  condiments 
and  spices.  One  may  also  include  vegetable  acids  and  alkaloids  as 
theine  in  tea,  caffeine  in  coffee  and  theobromine  in  cocoa. 


564  TROPICAL    HYGIENE,    SANITATION,    ETC. 

The   fo'iloiving    remarks    may    prove    useful:    An   average    diet    to 
nourish  an  adult  male  not  engaged  in  hard  work  should  be  :^ 

Protein,    70   to    80   grm.    per    diem 
Carbohydrate,  300  to  400  grm,  per  diem 
Fats,  25  to  50  grm.  per  diem 
Salts  and  vitamines 

\^ariety  and  laste  are  not  here  considered. 
A  menu  could  be  made  up  as  follows  :  — 


White  bread     ... 

...         ... 

...     400  grm 

Butter  or  margarine 

...       30     ', 

Bacon    ... 

...         ... 

50     ,. 

Sugar     ... 

..■        50     ,. 

Jam  or  conserves 

... 

...       30 

Quaker  oats 

.••       30     M 

Condensed  milk 

...         ... 

...       30     - 

Tea,  coffee  and 

cocoa  as  requ 

red. 

The  total  average  weight  of  solid  food  is  about  40  to  50  ounces 
daily. 

To  this  is  added  water  50  to  80  ounces  daily. 

A  man  consumes  daily  ^f^o  of  his  weight  of  dry  solid  food  and  r^o 
of  his  weight  as  water. 

Women  require  10  per  cent,  less  than  men,  children  of  ten  years  of 
age  half  as  much  as  a  woman. 

During  a  fair  day's  work  the  energy  expended  equals  one-fifth 
mechanical  labour  and  four-fifths  heat. 

Death  ensues  when  the  tissue  loss  is  about  40  per  cent,  of  the 
normal  bodv  weight.     This  is  from  starvation  only. 

The  common  ground  nut  (Arachis  hypogea)  would  be  a  good  food 
if  one  could  digest  all  one  could  consume,  as  it  contains  :  — 

Of  proteins,  24*5  per  cent.;  of  fatty  oil  50  per  cent.;  of  other 
nitrogenous  matter  iry  per  cent.;  salts  i'8  per  cent.;  water  7*5  per 
cent.;  fibre  4'5  per  cent. 

The  sov  bean  (Glycine  soja)  contains  in  comparison  proteins  35'3 
per  cent.;  fatty  oil  i8'9  per  cent.;  other  nitrogenous  matter  26  per 
cent.;  salts  4'6  per  cent.;  water  11  per  cent.;  fibre  4*2  per  cent. 

The  cassava  plant  is  a  common  food  in  the  tropics.  Of  it  there  are 
two  varieties,  viz.  :  the  sweet  (Manihot  aipi)  and  the  bitter  (Manihot 
utilissima).  The  latter  contains  a  small  amount  of  prussic  acid  in  its 
milkv  juice,  which  is  dissolved  out  when  meal  or  tapioca  is  made  from 
it.     The  latter  (tapioca)  contains  86  per  cent,  starch. 

The  chief  native  foods  are  cereals,  e.g.,  rice,  maize,  millet,  &c., 
all  deficient  in  fat  and  protein  which  is  somewhat  compensated  for 
by  the  pulses  and  the  beans. 

Dry  rice  when  boiled  absorbs  four  times  its  weight  of  water. 

Its  progress  through  the  stomach  is  slow,  the  latter  being  some- 
what distended  bv  it  for  several  hours.     Its  starch  is  well  digfested  in 


FOOD  565 

the  intestines.     The  best  rice  is  lacking  in  phosphoric  acid,  lime  and 
other  mineral  and  nitrogenous  matters. 

Eggs,  oil,  beans,  &c.,  should  be  taken  to  compensate  for  this. 

To  calculate  the  caloric  value  of  any  food  remember  that  :  — 

One    gramme    of    protein    equals    4'i     large    calories 
)j  i3.t  ,,         9'3  )) 

„  carbohydrates      4'i  ,, 

Voit's  standard  diet  is  :  — 

105   grammes  of  protein  x    41   equals      430    large  caloiies 

56  „  lat  X    9-3        „  520 

500  „  carbohydrates    x  4-1        ,,       2,050  ,, 

3'ooo  large    calories 

One  large  calorie  when  converted  into  mechanical  force  is  equal 
to  425  kilogram  metres  or  i'32  foot  tons,  hence  the  available  energy 
in  the  3,000  calories  would  be  3,000  x  425  equals  1,275,000  kilogram 
metres  or  3,960  foot  tons. 

An  average  man  of  11  stone  (70  kilos)  has  an  average  daily  waste 
of  nitrogen  20  grm.  and  carbon  320  grm.,  hence  his  food  must 
replace  this  waste  and  also  about  3,000  calories  for  mechanical  energy. 

Remember  that  to  obtain  16  grm.  of  nitrogen,  100  grm.  of 
nitrogen  must  be  ingested. 

An  average  ratio  of  daily  food  is,  according  to  Hutchison  : — - 

Protein  125,  fat  50,  carbohydates  500,  total  676  grm. 

Calories  3,027.     Nutrient  value  1:5. 

676  grm.  is  2r7  ounces  (one  ounce  equals  31 '104  grm.). 

Or  9'6  grm.  per  kilogram  of  body  weight. 

Or  o"i4i  ounces  per  pound  of  body  weight. 

Thus  taking  Voit's  standard  diet  as  above  it  would  be  classified 
thus  :  — 

In  24  hours  per  kilogramme  of  body  weight 

Grm.  Grm.  Ounces  Total  ounces 

Protein  118         ...         17         ...         0-025  •••  3'8 

Fat     ...  56         ...         0-8         ...         0-0I2  ...  1-8 

Carbohydrates         ...  500         ...         yi  ...         o'lio  ...  i6'o 


674  9-6  OT47  21-6 

One  may  consider  generally  that  an  average  male  requires  daily 

For  bare  sustenance  12-14  ounces,  equals  375-435  grammes 
For  moderate  work  20-23  v  v        622-775         ,, 

For  hard  work  21-25  „  .,        653-777        ,, 

A  native's  food  consisting  of  :  — 

Soy   beans    5    ounces    would    yield     protein    1765     starch    3*470 
Rice  16  „  „  1-163         ,,      12-752 


2-928  l6-222 

The  beans  are  also  rich  in  oil,  the  above  containincr  about  ^r  erm, 


566  TROPICAL    HYGIENE,    SANITATION,    ETC. 

or  an  ounce.     There  should  be  about    i|  ounces   in   his  diet.     This 
would  be  a  fair  native  diet  but  some  variety  is  essential. 

Meat  proteins  are  more  easily  assimilated  than  those  of  vegetable 
products  and  repair  the  tissues  more  rapidly  in  the  proportion  of  97 

to  80. 

Onlv  50  per  cent,  of  protein  should  be  procured  from  meats,  the 
remainder  from  vegetables  and  bread.  Quantities  above  this  place  too 
much  strain  on  the  kidneys  and  liver.  Over-eating  is  common  in  the 
tropics,  which  is  so  often  accompanied  by  a  sedentary  life. 

Hindus  take  no  animal  food  except  that  in  milk  and  ghee,  but 
they  are  neither  robust  nor  active. 

There  must  be  a  necessary  modification  of  diet  to  suit  the  climate. 

The  Hindu  can  live  and  fare  well  on  rice  principally  while  the 
Esquimaux  require  large  quantities  of  fat  to  maintain  their  body  heat. 

Salted  rations  only  will  produce  disease,  as  happened  in  the  first 
Burmese  War  and  in  the  Cameroons.  On  the  other  hand  excess  of 
fresh  meat  will  cause  intestinal  disorders  as  happened  in  the  French 
campaign  in  Algeria  and  in  the  American  Civil  War,  when  the 
enemy's  cattle  were  captured  and  eaten. 

The  Aryan  races  were  meat  eaters  when  they  invaded  India,  but 
now  they  are  practically  vegetarians. 

Meat  extracts  are  not  a  concentrated  form  of  nourishment,  such 
exist  in  name  only.  There  is  no  true  meat  extract.  About  four-fifths 
of  the  nutritive  constituents  of  meat  existing  in  the  muscle  fibre  are 
insoluble  in  either  hot  or  cold  water,  but  they  are  rendered  soluble  when 
acted  on  by  the  pancreatic  and  gastric  juices,  hence  nutritive  con- 
stituents cannot  be  present  in  water  preparations. 

Some  of  the  connective  tissue  can  be  dissolved  out  as  gelatine  but 
its  nutritive  powers  are  very  low  and  even  then  it  is  not  a  true  tissue 
former.  Small  quantities  of  albumin  which  are  soluble  in  cold  water 
are  insoluble  after  being  coagulated  in. hot  water.  This,  however^ 
will  yield  to  the  digestive  juices. 

The  meat  bases,  e.g.,  creatinine,  zanthine,  &c.,  and  half  the  salts 
are  dissolved  out  bv  water,  the  former  being  nerve  stimulants  like  the 
caffeine  of  coffee  and  are  not  nutrients. 

When  the  above  nutrients  have  been  peptonized  they  can  be  taken 
in  medicinal  doses  only,  as  increased  quantities  cause  purging  and 
hence  cannot  be  foods.  One  pound  of  beef  steak,  about  450  grm.,  is 
about  all  the  flesh  former  a  man  of  eleven  stone  requires  in  twenty-four 
hours,  which  in  ex-war  times  costs  about  two  shillings.  The  approxi- 
mate equivalent  in  meat  extract  would  be  six  bottles  of  4  ounces  each,, 
costing  los.  6d.  as  against  is.  for  the  real  thing.  In  addition  to 
that  its  consumption  would  be  unAvise  because  it  would  contain  a 
dangerous  amount  of  nerve  excitant  and  3J  ounces  of  common  salt. 
How  can  such  preparations  be  called  "  meat  extracts  "  ? 


FOOD  567 

When  salt  in  such  quantities  is  ingested  i'  requires  about  100  parts 
to  one  of  water  to  correct  it  and  hold  it  in  solution  in  the  body.  Such 
weight  of  water  should  not  be  mistaken  for  healthy  increase,  it  is  a 
serious  symptom. 

Such  preparations,  however,  when  taken  in  small  (juantities  have  a 
limited  use. 

Sausages.  These,  as  commercially  made,  are  not  as  nutritive  as 
they  could  be.  Only  too  often  there  have  been  discovered  amongst 
the  ingredients  such  materials  as  :  boiled  rice,  soaked  bread,  steamed 
potatoes,  sawdust  and  pulped  wood.  Preservatives  and  blood  colour- 
ing matters  are  only  too  frequently  used.  The  tropical  resident  would 
do  well  to  avoid  all  tinned  sausages. 

Cereal  breakfast  foods,  such  as  Quaker  Oats,  &c.,  are  always  good, 
but  the  endless  variety  of  proprietary  breakfast  foods  cannot  improve 
upon  the  real  thing  with  regard  to  nutrition.  Some  of  them  may  be 
partly  predigested,  but,  apart  from  invalids,  this  is  not  an  advantage. 

Whole  milk  cheese  is  made  from  coagulum  formed  from  milk, 
treated  with  rennet  or  acid  or  allowed  to  sour  spontaneously.  It  is 
then  known  as  cream  cheese,  otherwise  it  is  drained,  salted  and  left  to 
ferment.     A  good  variety  contains  :  — 

Water,  34  to  40  parts;  protein,  20  to  30;  fat,  25  to  35;  milk  sugar, 
1  to  3 ;  mineral  salts,  3  to  6  parts. 

Ripening  is  caused  by  yeasts,  moulds  and  lactic  acid  bacteria,  caus- 
ing decomposition  of  the  sugar  principally,  the  by-products  being 
very  numerous.  The  micro-organisms  number  from  450,000,000  to 
450,000,000,000  per  pound.  Nevertheless,  whole  milk  cheese  is  one  of 
the  most  nutritious  of  foods.  One  pound  contains  about  as  much 
protein  as  ij  pounds  of  meat. 

Proprietary  protein  foods  are  prepared  from  milk  casein,  waste 
meat  fibre,  vegetable  gluten  and  a  mixture  of  these  treated  chemically. 

vSome  of  them  contain  large  quantities  of  protein  and  mav  in 
selected  cases  be  taken.     Their  constant  consumption   is  not  advised. 

]\Lilk  when  pure  is  an  excellent  food.  It  should  be  sipped,  as 
Nature  intended  and  not  swallowed  like  a  glass  of  water.  Curds  in  the 
stomach  may  cause  a  disagreeable  train  of  svmptoms.  One  must 
remember  that  milk  contains  solids  to  the  extent  of  i   in  8. 

Milk  is  both  a  food  and  a  beverage. 

It  is  best  to  boil  all  milk  in  the  tropics  to  avoid  infection  bv  the 
organisms  of  undulant  fever  and  other  diseases. 

When   heating  milk   remember  that  :  — 

The  rennin  enzyme  is  destroyed  at  60^  C.  —  140"  F. 

All  micro-organisms  are  destroyed,  not  spores  at      ...     68'"  C.  —  154''  F. 
The  Pasteurization  temperature  is        ...         ...         ...     75*-'  C.  —  167°  F. 

The  boiling  temperature  is  ...         ...         ...         ...    loi"  C  —  2I3'5''  F. 

All  germs  are  destroyed  in  one  hour  if  under  pressure  at  105^  C.  —  221°  F. 

36 


568  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Homogenised  milk  has  the  fat  globules  broken  up  by  powerful 
mechanical    means   and    is   consequently   more    easily    digested. 

Shimnu'd  milk  may  be:  — 

Hand  skimmed,   that   is  deprived  of  its  cream  after  standing. 

Machine  skimmed,  better  known  as  separated  milk. 

The  latter  is  less  nutritious  than  the  former,  separated  milk  only 
containing  fat  o'lo  to  o'45  per  cent,  as  against  075  to  i  per  cent,  in 
hand  skimmed.  Skimmed  milk  should  contain  at  least  9  per  cent, 
of  non-fatty  solids. 

Condensed  milk  is  made  by  concentration  in  vacuum  pans  at  a 
low  temperature,  50°  C.  or  132°  F.  and  then  sugar  added. 

There  are  several  varieties  as  :  — 

Whole  milk,  sweetened  and  unsweetened. 

Skimmed  milk,   sweetened  and  unsweetened. 

The  volume  is  reduced  to  about  one  third  of  the  original  quantity. 

The  amount  of  sugar  added  is  from  30  to  50  per  cent,  of  the 
finished  product.  It  is  never  sterile,  but  pathogenic  germs  are 
almost  invariably  absent. 

Dried  milk  is  used  more  in  the  confectionery  trades  than  in  ordinar}' 
consumption.  It  can  be  taken  in  six  and  a  half  parts  of  water,  when  it 
equals  cow's  milk  in  its  concentration. 

Dried  skimmed  milk  should  not  be  used  for  infants.  It  may  be 
used  in  cooking,  i  in  10  of  water. 

Butter  milk  is  similar  to  skimmed  milk,  but  is  soured  by  lactic  acid 
fermentation.  It  is  not  very  palatable.  The  flavour  disappears  in  the 
cooking. 

ir/zcy  is  produced  in  cheese  making.  When  rennet  is  added 
coagulation  takes  place;  casein  is  thrown  down  with  the  fat  forming 
the  curd,  the  remaining  fluid  being  known  as  sweet-whey ;  but  when 
it  is  allowed  to  sour  spontaneously  this  fluid  is  known  as  sour-whey. 

It  is  useful  for  fever  cases,  but  it  is  less  nourishing  than  milk. 

Buffalo's  milk  is  twice  as  rich  in  fat  as  cow's  milk,  and  contains  a 
larger  amount  of  total  solids. 

Ghee  can  be  prepared  from  the  milk  of  the  cow  or  buffalo. 

The  milk  is  curdled  with  dobi  or  sour  milk,  churned,  water  added, 
upon  the  top  of  which  the  butter  floats;  the  latter  is  collected,  washed, 
placed  over  a  fire  in  an  iron  pan;  the  butter  melts,  casein  and  water 
fall  to  the  bottom,  which  is  collected  and  called  Kutcha  ghee,  or  if  the 
heat  is  increased  so  as  to  evaporate  the  water  and  slightly  char  the 
casein,  it  is  called  "pucka"  or  Valo  ghee. 

The  former  is  used  in  the  preparation  of  sweetmeats  and  food-stuffs ; 
the  latter  is  often  mixed  with  rice  or  spread  on  bread.  It  is  also  used 
for  religious  purposes. 

Goat's  milk  cream  is  in  finer  globules  than  that  of  cow's,  and  does 


FOOD  569 

not  so  readily  separate  out.  It  should  always  be  tried  when  cow's 
milk  is  not  available.  It  is  not  sufficiently  appreciated  in  some  parts 
of  the  tropics. 

Yitamines. 

Vitamines  are  essential  food  substances  without  which  some 
deficiency  disease  soon  sets  in.  They  are  contained  in  rice  polishings 
and  veast,  hence  the  former  should  not  be  rejected.  They  prevent 
polyneuritis.  Vitamines  (CO  (NH)^  CieHigOg  ?)  belong  to  the 
Pyramidine  group,  and  may  be  a  constituent  of  nucleic  acid.  They 
are  nitrogenous  bodies  which  do  not  contain  phosphorus  or  fat.  They 
are  soluble  in  alcohol  and  water.  They  are  crystallizable  and  not 
destroyed  by  boiling  water.  They  are  unimpaired  when  milk  is 
sterilized  or  pasteurized.  They  are  found  in  all  food-stuffs  in  a  minute 
quantity,  but  they  are  more  plentiful  in  commercial  lecithin,  milk,  ox 
brain  and  brewer's  yeast.  They  are  probably  the  mother  substances 
of  ferm.ents  and  hormones.  They  are  destroyed  at  i20°-i30°  C.  in 
twenty  rninutes,  and  also  by  extreme  dryness. 

ADULTERATION  OF  FOODS. 

Adulterants  in  milk  are  common  in  the  tropics,  such  as  :  — 
(i)  Sewage  from  w^ells,  tanks  and  ponds. 

(2)  ]\Iolasses  or  potassa  to  raise  the  specific  gravity  after  adding 
water. 

(3)  Arrowroot  and  pulped  banana.  Cream  is  usually  removed  from 
milk  samples  where  these  adulterants  are  used. 

(4)  Preservatives  are  not  so  commonly  used. 
Test  for  nitrites  in  milk. 

Coagulate  a  little  milk  in  a  test-tube  with  acetic  acid. 

Filter,  add  to  the  filtrate  a  few  c.c.  of  sulphanilic  acid  and  naphthyl- 
amine  sulphate,  equal  parts;  a  rose-red  colour  is  positive  for  nitrites. 

Test  for  nwlasses  and  botassa. 

To  one  test-tube  containing  10  c.c.  of  milk  add  5  grm.  of  ammonium 
molybdate  and  10  c.c.  of  dilute  alcohol  (i  in  10). 

To  a  second  test-tube  place  6  per  cent,  solution  of  lactose  and  treat 
as  above. 

Place  both  test-tubes  in  a  water  bath  and  raise  the  temperature 
gradually  to  80°  C. 

A  blue  coloration  in  the  tube  is  positive  for  cane  sugar,  while 
lactose  is  unaltered. 

This  test  will  detect  o'l  per  cent,  of  cane  sugar. 

Another  test. 

To  10  c.c.  of  milk  add  o"i  grm.  of  resorcin  and  a  few  drops  of  HCl 
Boil  for  a  few  minutes. 


570  TROPICAL    HYGIENE,    SANITATION,    ETC. 

A  rose-red  colour  is  positive  for  cane  sugar. 

Anv  deposit  should  be  examined  with  a  microscope  for  starch,  pus, 
ind  dirt  which  can  be  readily  detected. 

Milk  with  a  specific  gravity  below  i"028  contains  an  exceptional 
amount  of  cream  or  has  been  adulterated.  It  is  normally  i "028-1  "035. 
If  there  is  less  than  3  per  cent,  of  fat  it  has  usually  been  adulterated. 

Bacterially  milk  should  be  examined  for  the  tubercle  bacillus  and 
the  cholera  vibrio.     The  tubercle  bacillus  is  rarely  found  in  India. 

For  T.B. 

Centrifuge  a  small  quantity  of  milk. 

Take  the  deposited  portion  and  inoculate  two  guinea-pigs. 

If  T.B.  is  present  the  animals  will  show  it  in  three  to  six  weeks. 

The  tuberculin  reaction  is  useful  for  cows. 

For  cholera  vibrio. 

Isolate  in  Durham's  peptone  solution  with  i  c.c.  of  milk  and  plate 
out.  Identifv  the  organisms.  For  more  details,  see  special  section 
on  Laboratory  Hints. 

Milk  may  be  manipulated  as  follows  :  — 

(New  South  Wales   Report  of  the  Government  Bureau,    1909). 
(i)  Mechanical  contrivances. 
Centrifugalization . 
Filtering. 

(2)  The  application  of  heat. 

Sterilization. 
Boiling. 
Pasteurization. 
Concentration. 
Desiccation. 

Thermophore    treatment,    similar    to    thermos    treatment,    to 
prevent  excessive  growth  of  bacteria  by  continuous  warming. 

(3)  The  application  of  cold. 

Freezing. 
Chilling. 
Cooling. 

(4)  The  addition  of  antiseptics. 

Sodium  bicarbonate. 

Boric  acid,  borax  or  mixtures. 

Formalin. 

Salicylic  acid. 

Peroxide  of  hydrogen. 

(5)  The  inducement  of  alcoholic  fermentation. 

Koumiss. 
Kepiiir,  &c. 


FOOD  571 

Butter. 

Butter   may   be   adulterated    by  :    adding   an   excessive   amount    of 

water, 
reducing  its  fat  content, 
adding  milk  or  milk  powder. 

Artificial  colouring  is  allowed,  as  also  are  some  preservatives. 

Excess  of  water  is  commonest,  and  may  be  present  as  the  result 


of 


Carelessness  in  making,  by  having  too  high  a  temperature  when 
churning  or  to  deliberate  intention. 

12-14  P^r  cent,  is  not  excessive.  16  per  cent,  should  constitute 
grounds  for  prosecution. 

If  there  is  more  than  i  per  cent,  of  curd  suspect  added  milk,  and 
test  for  milk  sugar. 

Foreign  fats  are  frequently  added.  Those  usually  employed  are 
lard,  beef  fat,  cotton-seed  oil  and  cocoanut  oil,  or  a  combination  of 
these.  Artificial  preparations,  containing  tributyrin  or  triacetin  in 
alcoholic  solution,  are  even  added  to  make  up  for  the  increase  in 
volatile  fatty  acids  caused  by  the  use  of  animal  fats. 

Special  works  must  be  consulted  for  their  detection. 

For  butter  analysis,  see  Laboratory  Hints. 

For  preservatives  and  their  excesses,  see  p.  574. 

SOME  MORBID  CONDITIONS  CAUSED  BY  FOOD. 

Scurvy. — This  disease  is  probably  due  to  a  deficiency  of  fresh 
vegetables  and  fruits;  it  is  known  as  a  deficiency  disease. 

Partial  decomposition  of  preserved  foods  and  a  damp,  low-lying 
locality  may  also  be  predisposing  factors. 

The  symptoms  are  due  to  blood  changes  causing  :  marked  debility, 
sallow  complexion,  swollen,  spongy  and  ulcerated  gums,  effusion  and 
haemorrhage  into  the  joints,  accompanied  by  foul  ulcers  and  dysentery. 
The  condition  should  be  corrected  by  giving  fresh  lemon  or  lime  juice, 
fresh  vegetables,  fruits,  potatoes,  yams,  green  vegetables  and  yeast. 

Rickets. — This  is  probably  due  to  a  deficiency  of  fat  and  protein 
with  excess  of  starches  in  children's  diet,  and  is  hence  known  as  a 
deficiency  disease. 

Artificial  starchy  foods  cannot  be  digested  by  infants. 

Intestinal  Disorders. — These  are  caused  by  decomposed  and  mouldy 
grains.  Such  should  be  always  condemned  as  unfit  for  human  con- 
sumption. 

Beriberi. — This  is  in  all  probability  a  deficiency  disease  usually 
found  amongst  rice-eating  peoples.  The  essential  vitamines  are  con- 
tained in  the  rice  polishings  which  are  so  often  rejected. 

For  details,  see  article  on  Beriberi. 


572  TROPICAL    HYGIENE,    SANITATION,     ETC. 

Pellagra. — In  all  probability  another  deficiency  disease  about  the 
cetiology  of  which  there  is  still  much  disagreement.  See  article  on 
same  for  details. 

Lathyrism  is  caused  by  eating  the  Lathyrus  sativus,  a  vetch  used 
as  a  grain  at  famine  times  by  the  poor  of  India.  The  toxin  affects  the 
pyramidal  tracts  of  the  cord. 

Ergotism  is  produced  by  the  mycelial  fungus,  Claviceps  purpurea, 
in  rye.  It  causes  sclerosis  of  the  posterior  columns  of  the  cord  and 
stimulation  of  the  vasomotor  centre. 

Beriberi,  Pellagra,  Lathyrism  and  Ergotism  are  somewhat  allied 
in  symptomatology,  all  producing  nervous  affections,  the  three  latter 
affecting  the  spinal  cord. 

The  subject  mav  also  be  considered  from  the  point  of  view  of  the 
causative  agent  thus  :  — 

Milk,  when  decomposed,  forms  lacto-toxin  or  tyro-toxin,  producing 
outbreaks  of  nausea,  vomiting,  dry  mouth  and  fauces,  diarrhoea, 
cramps  and  collapse. 

Infected  milk  disseminates  Undulant  fever,  Cholera,  Typhoid 
fever,  Dysentery  and  Tuberculosis. 

Meat   when   decomposed  and    infected    produces   a   diarrhoea   of   a 
choleraic   nature  with   vomiting,    cramps,    headache,    prostration,    &c., 
due  to  organisms  of  the   Gaertner   group,    principally    B.   enteritidis, 
B.  botulinus,  and  B.  enteritidis  sporogenes. 
Infective  conditions  are  produced  when  :  — 
Tcenice  are  found  in  beef,  mutton,  pork  and  dog  meat. 
Trichincp  in  "measly"  pork. 
Strongylus  filaria  in  the  lungs  of  sheep. 
Distoma  hepaticurn  in  the  liver  of  sheep  and  cattle. 
Ccenurus  cerehralis  in  the  brain  of  sheep  and  cattle. 
Watercress  may  contain  the  encysted  forms  of  trematodes,  ova  and 
bacteria  of  Enteric,   Cholera  and  Dysentery.     This  is  particularly  so 
when  the  garden  has  been  tended  by  a  Chinaman. 

Fresh  fish  and  shell  fish  mav  acquire  poisonous  properties  when 
spawning,  while  other  fish  in  the  tropical  seas  are  unsafe  owing  to 
their  feeding  on  poisonous  medusae  and  corals. 

Oysters  have  been  responsible  for  Cholera  in  India  and  Typhoid 
fever  in  man\'  parts. 

Canned  fresh  herrings  and  sardines  have  been  found  to  yield  a 
metallic  tin  content  in  the  fish  of  from  2-5  grains  per  pound  (Everitt 
Atkinson). 

THE  EXAMINATION  OF  MEATS. 
Good  fresh  meat  should  be  firm,  elastic,  not  tough,  should  not  pit 
on  pressure.     Thin  red  meat  juice  .should  exude  from  it  on  standing. 
It  should  be  red  throughout,  not  pale,  purple,  or  green  in  parts. 


FOOD  57-, 

It  should  be  free  from  purulent  or  gelatinous  fluids  in  the  septa 
between  muscular  bands. 

It  should  be  fresh  and  pleasant  to  the  smell,  after  the  insertion  of 
a  skewer  or  cutting  it  with  a  knife. 

The  reaction  should  be  slightly  acid.  Alkalinity  denotes  decom- 
position.    It  should  be  free  from  "  spots  "  which  are  cysticerci. 

The  fat  should  be  free  from  hemorrhages,  firm,  white,  seldom 
yellow,  and  never  gelatinous. 

Goat  flesh  has  less  fat  than  mutton  and  is  somewhat  darker. 

Carcases  of  sheep  should  have  the  feet  attached  to  distinguish  them 
from  goat  meat. 

Good  preserved  meat  in  tins  should  have  the  ends  of  the  tins 
slightly  concave.  All  tins  that  show  signs  of  bulging  should  be  con- 
demned as  the  tin  has  not  been  rendered  sterile,  the  retained  micro- 
organisms producing  the  gas  which  distends  the  tin. 

Tins  sounding  hollow^  when  struck  with  a  w^ooden  mallet  should  be 
examined  more  critically. 

Frozen  meat  should  be  refused  when  the  pleurae  have  been  stripped 
from  the  carcases. 

Prolonged  refrigeration  for  several  weeks  is  fatal  to  cysticerci. 

Partially  decomposed  meat  is  neutral  or  alkaline  in  reaction,  easily 
tears,  pits  on  pressure,  and  usuallv  has  an  offensive  odour. 

THE  EXAMINATION  OF  LIVING  ANIMALS. 

Healthv  live  animals  should  appear  well  nourished,  able  to  walk 
with  ease,  bright  eyed,  breathing  quietly  and  without  offensive  odour, 
mouth  and  nostrils  cold,  moist  and  without  discharge,  coat  smooth 
and  free  from  eruption,  not  rough,  no  shivering,  diarrhoea,  &c. 

All  organs  should  be  healthy  when  killed. 

When  the  animal  is  slaughtered  one  should  examine  the  chest  wall, 
pleurjfi,  diaphragm  and  lymphatic  glands.  One  should  look  for 
dropsical  fluids  in  the  connective  tissue  in  the  flanks,  under  the 
shoulders  and  armpits,  beneath  the  diaphragm,  above  and  behind  the 
kidneys. 

Examine  for  glistening  spots  or  bladder-like  bodies,  and  confirm 
with  a  microscope  in  doubtful  cases. 

When  the  carcase  is  ill-bred,  bile-stained,  with  patches  of  extra- 
vasations, the  viscera  congested  and  dark-coloured,  suspect  infectious 
disease  as  Anthrax  and  Piroplasmosis. 

Exclude  the  following  diseases  by  the  microscope  when  possible  :  — 

Anthrax  by  absence  of  the  anthrax  bacillus  in  the  blood. 

Piroplasmosis  by  absence  of  Piroplasma  bigeminum  in  the  blood. 

Pasteurellosis  by  absence  of  small  encapsulated  diplococcus  in  the 
gland  juice,  &c. 


574  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Swine  fever,  Swine  tvphus,  Pneumo-enteritis  and  Hog"  cholera  by 
the  examination  of  the  lungs  and  intestine  after  death. 

Rinderpest  by  absence  of  abrasions  of  the  mouth  and  tongue,  con- 
gestion with  cheesy  deposits  on  the  throat  and  nostrils,  crackling  on 
pressure  in  advanced  stages. 

Pleuro-pneumonia  by  absence  of  hepatization  of  the  lungs  after 
death. 

Tuberculosis  by  absence  of  small  tubercles  or  caseous  masses  in  the 
lungs,  on  the  pleurae,  peritoneum,  liver,  kidneys,  and  without  the 
enlargement  of  the  l\'mphatic  glands  of  the  carcase. 

Actinomycosis  by  the  absence  of  the  rav  fungus  (Streptothrix 
actinomyces)  about  the  upper  and  lower  jaws  and  the  nasal  cavities. 
There  should  be  no  interstitial  inflammation  of  the  tongue  (woody 
tongue). 

T^niasis  by  absence  of  cysticerca  amongst  the  muscle  fibres  of  the 
carcase. 

Trichinosis  by  the  absence  of  Trichinae  spiralis  in  the  flesh  of 
animals  that  destroy  rats,  such  as  pigs,  &c.  Each  capsule  ingested 
gives  rise  to  a  brood  of  one  or  several  hundred  young  trichinae. 

Coccidiosis  of  rabbits,  cattle  and  sheep  by  the  absence  of  the 
psorosperms.  The  chief  ones  are  Coocidium  oviforme.  They  are 
found  about  the  bile  ducts  and  intestines  of  carcases. 

Tuberculosis. — With  regard  to  this  vexed  question  the  recom- 
ynendations  of  the  Royal  Commission  on  Human  and  Animal  Tuber- 
culosis are  :  — 

The  carcase,  if  otherwise  healthy,  shall  not  be  condemned,  but 
every  part  of  it  containing  tuberculous  lesions  shall  be  seized  when — 

(i)  The  lesions  are  confined  to  the  lungs  and  the  thoracic  Ivmphatio 
glands. 

(2)  The  lesions  are  confined  to  the  liver. 

(3)  The  lesions  are  confined  to  the  pharyngeal  lymphatic  glands. 

(4)  The  lesions  are  confined  to  any  combination  of  the  foregoing, 
but  are  collectively  small  in  extent. 

The  entire  carcase  and  all  the  organs  may  be  seized  when — 
(.1)  There  is  miliary  tuberculosis  of  both  lungs. 

(2)  Tuberculous  lesions  are  present  on  the  pleura  or  peritoneum. 

(3)  Tuberculous  lesions  are  present  in  the  muscular  system,  or  in 
the  lymphatic  glands  embedded  in  or  between  the  muscles. 

(4)  Tuberculous  lesions  exist  in  any  part  of  an  emaciated  carcase. 

MEAT  PRESERVATION. 

From  ancient  times  certain  methods  and  means  have  been  adopted 
for  the  preservation  of  meats,  especially  where  all  that  in  hand  could 
not  be  consumed  within  a  reasonable  time. 


FOOD  575 

Primitive  peoples  adopt  such  methods  as  smoking,  saUing  or 
pickHng. 

Modern  peoples,  on  the  other  hand,  use  such  chemical  materials 
as  sodium  benzoate,  salicylic  acid,  &c.,  which  when  present  in  food 
in  sufficient  quantity  to  preserve  it  are  tasteless,  odourless,  and  can 
onlv  be  known  by  the  label  or  chemical  analysis. 

The  old-fashioned  methods  of  salt  and  smoke  had  much  in  their 
favour. 

It  should  not  be  forgotten  that  fresh  meat  can  be  kept  for  four  to 
six  days  as  a  result  of  boiling  it  slightly  each  morning. 

Meat  preservation  is  all-important  for  the  tropics  and  ocean 
steamers.     Some  method  of  preservation  is  essential. 

The  methods  usually  employed  are  (after  Whitelegge  and 
Newman)  :  — 

(i)  Exclusion  of  air. 

The  meat  may  be  dipped  into  boiling  water,  when  the  external 
coagulated  albumin  forms  an  impervious  layer,  or  it  may  be 
coated  by  paraffin  or  fat. 

(2)  Preservative  Injections. 

Inject  the  blood-vessels  with  water,  then  with  a  solution  of 
common  salt,  or  alum  with  aluminum  chloride. 

(3)  External  Preservatives  as  :  — 

Salt  or  brine,  sugar,  boric  acid,  weak  carbolic  acid,  &c. 

(4)  Pickles. 

Salt  and  a  little  potassium  nitrate  are  mixed  together  and  well 
rubbed  in. 

(5)  Drying  after  exposure  to  smoke  from  a  wood  lire. 
This  is  the  favourite  method  of  natives. 

(6)  Refrigeration. 

The  application  of  cold,  just  above  freezing  point,  must  be 
continuous.  Decomposition  is  rapid  when  the  cold  is  with- 
drawn if  rigor  mortis  had  set  in  before  the  freezing. 

(7)  Sterilised  Enclosures. 

Hermetically    sealed    in   vessels   in    vacuo   or   in    sterilized   air. 
The    air    is    expelled    previous    to    sealing   by    boiling,    steam, 

chemicals,   e.g.,   sodium  sulphite,  &c. 
Imperfections    in    sterilization    result    in    partial    decomposition 
of  the  contents  and  when  ingested  of  toxic  symptoms  in  the 
consumer. 
The  dangers  from  tinned  foods  are  from  :  — 
(i)  Added  preservatives  in  excess. 

(2)  Colouring  agents. 

(3)  Salts  of  tin,   lead  and  zinc  from  chemical   reaction   in   the  tin. 

(4)  Absence  of  vitamines. 


576  TROPICAL    HYGIENE,    SANITATION,    ETC. 

The  most  common  chemical  preservatives  are  :  — 

Formaldehyde  and  Borax  to  milk. 

Salicylic  acid  to  fruit  juices. 

Sodium   henzoate  to  ketchup,  jams  and  sauces. 

Sulphites  to  dried  fruits,  gelatin  and  chopped  meat. 

Fluorides  to  beer. 

Some  of  these,  such  as  salicylic  acid,  borax,  benzoic  acids,  and 
fluorides  are  normally  present  in  certain  products,  hence  their  mere 
presence  cannot  always  mean  that  such  have  been  added. 

Minute  amounts  of  preservatives  of  a  certain  specified  kind  are 
essential  in  most  cases  but  there  is  not  the  slightest  doubt  that  the 
opportunity  to  add  preservatives  by  unscrupulous  manufacturers  is  a 
constant  temptation  to  put  on  the  market  food  unsuitable,  and  partly 
decomposed.  When  preservatives  are  added  to  arrest  decomposition 
the  quantity  must  be  sufficient  to  interfere  with  the  normal  digestion 
of  the  consumer. 

The  following  notes  may  be  of  interest. 

The  nutritive  value  of  meat  after  refrigeration  is  unaltered. 

Salt  in  butter  causes  mycelial  fungi  to  disappear  and  reduces  the 
vigorous  multiplication  of  micro-organisms. 

Formaldehyde  in  small  quantities  is  apt  to  cause  headache;  nausea, 
vomiting  and  intestinal  cramps. 

Boric  acid  rubbed  on  hams  penetrates  the  substance  deeply  and  its 
consumption  mav  derange  the  digestive  tract. 

Boric  acid,  20  grains  to  the  pound,  was  found  in  certain  sausages. 

This  inhibits  putrefaction  but  does  not  appreciably  inhibit  the 
growth  of  ihe  Coli  group  of  organisms,  hence  stale  meat  can  be  used 
for  sausages  (Bernstein). 

Certain  preserved  tinned  lobsters  contained  from  o"8o  to  4*47  grains 
per  pound  of  dissolved  metal  in  their  contents.  More  than  i  to  8 
grains  has  caused  poisoning.  As  much  as  13  grains  per  pound  has 
been  found  (Wiley). 

Copper  sulphate,  added  to  make  vegetables  a  nice  green  colour,  'S 
unnecessarv,  unwholesome  and  unadvisable. 

The  black  spots  sometimes  seen  on  chilled  beef  are  due  to  a 
mycelium,  Oidium  carnis,  and  though  unsightly  are  harmless. 

The  following  organisms  have  been   found   in  preserved  fish,   sar- 
dines,  &c.,    B.    enteritidis   (Gaertner),    B.    prodigiosus,    B.   botulinus, 
Penicillium  glaucum,   Aspergillus  glaucus  and  others. 
Davies  proposes  : — 

All  preservatives  in  milk  should  be  forbidden. 

Borax  preservative  in  hams,  bacon  and  sausages  should  be  allowed. 
Salicylic  acid  in  wines  and  jams  to  be  allowed. 


FOOD  577 

Nil  else  siiould  be  permitted  without  permission  from  the  Board  of 
Agriculture. 

Good  firms  turn  out  canned  products  which  are  a  great  boon  to 
most  tropical  residents. 

For  quiilitatwe  and  quantitative  tests  for  preservatives  a  larger 
work  should  .be  consulted.  We  venture  to  give  here  one  simple 
qualitative  method  for  each  principal  preservative. 

Formaldehyde. 

Put  5  c.c.  of  milk  in  a  test  tube. 

Add  to  this  5  c.c.  of  the  liquid  to  be  tested. 

Pour  carefully  down  the  side  5  c.c.  of  concentrated  sulphuric  acid 
so  that  it  shall  not  mix  with  the  diluted  milk. 

A  violet  ring  at  the  junction  of  the  two  liquids  is  positive  for 
formaldehyde.     The  delicacy  of  the  test  is  about  i  part  in  200,000. 

Note. — Pure  sulphuric  acid  does  not  give  the  test.  In  commercial 
acid  some  ferric  salts  are  present  which  produce  the  test.  Hence  if 
onlv  pure  sulphuric  acid  is  to  hand  add  a  little  ferric  chloride. 

Benzoic  Acid  and  Sodium  Benzoate. 

This  salt  is  very  widely  used  in  many  varieties  of  foods. 

If  the  material  is  a  liquid,  acidify  25  c.c.  with  5  c.c.  of  sulphuric 
acid  and  shake  with  25  c.c.  of  ether  in  a  separatory  funnel. 

If  the  substance  is  not  fluid,  dilute  it  or  macerate  it  and  obtain  a 
watery  solution  of  it,  strained  and  treated  as  above. 

The  mixing  must  be  thorough  but  not  violent  as  emulsions  may  be 
formed. 

Separate  the  other  layer  and  evaporate  it  at  a  low  temperature. 

If  the  original  material  contained  much  fat  shake  the  ether  with 
ammonia,  evaporate  and  test  the  residue. 

Crystalline  scales  mav  be  seen  in  the  residue  which  give  off  a 
characteristic  odour  when  heated  if  much  benzoic  acid  was  present. 
The  residue  must  be  tested  as  follows  :  — 

Add  to  the  residue  2  to  3  c.c.  of  concentrated  sulphuric  acid. 

Heat  until  the  acid  gives  off  fumes  strongly. 

The  benzoic  acid  is  changed  to  sulpho-benzoic  acid,  in  the  charring. 

Add  ammonia  nitrate  in  small  portions  while  it  is  still  fuming. 

The  organic  matter  is  oxidized  and  m-dinitrobenzoic  acid  formed. 

Let  it  cool. 

Add  water  and  ammonia  in  excess,  transfer  to  test  tube. 

Pour  down  side  of  test  tube  a  little  freshly  prepared  colourless 
ammonium  sulphide.     It  must  not  be  mixed. 

A  red  ring  at  the  junction  of  the  two  fluids  is  positive  for  benzoic 
acid  and  is  due  to  ammonium  m-diamidobenzoate. 


578  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Add  a  few  drops  of  ammonium  sulphide  to  the  remainder  in  the 
casserole  and  a  red  colour  will  form  in  clouds  on  the  surface. 

Salicylic  Acid. 

Prepare  a  solution  as  for  benzoic  acid  test,  but  50  grm.  only. 

Divide  solution  into  two  portions  as  benzoic  acid  and  salicylic  acid 
are  often  present  together  in  the  same  supply. 

Wash  twice  with  one-tenth  of  its  volume  of  water  when  one  has 
prepared  the  other  extract  as  for  benzoic  test. 

The  washing  is  to  get  rid  of  the  mineral  acid  as  the  test  is  much 
more  delicate  in  its  absence. 

Evaporate  ether  in  porcelain  dish. 

To  residue  add  two  drops  of  dilute  (i  per  cent.)  ferric  chloride 
solution. 

Or  better,  three  to  four  drops  of  ferric  alum  solution. 

Rub  it  around  with  a  glass  rod. 

A  violet  colour  is  positive  for  salicylic  acid. 

If  positive  confirm  by  another  test  as  several  other  organic  sub- 
stances give  the  coloration. 

To  the  solution  to  be  tested  add  four  to  five  drops  of  a  10  per  cent, 
solution  of  potassium  or  sodium  nitrite. 

Add  four  to  live  drops  of  acetic  acid. 

Add  one  drop  of  ro  per  cent,  solution  of  copper  sulphate. 

Heat  to  boiling. 

A  reddish  tinge  is  positive  for  salicylic  acid. 

There  may  be  sufficient  to  give  a  blood  red. 

Phenol  gives  the  same  reaction  but  benzoic  acid  does  not. 

As  salicylic  acid  occurs  naturally  in  some  fruits  not  more  than 
50  grm.  of  the  substance  to  be  examined  should  be  taken. 

This  is  known  as  the  Jorissen  test. 

Boric  Acid  and  Borax. 

The  turmeric  paper  test  is  useful. 

Take  25  grm.  of  the  sample. 

Make  distinctly  alkaline  with  sodium  hydroxide. 

Evaporate  to  dryness  in  a  porcelain  dish. 

Boil  Avith  15  c.c.  of  water. 

Add  hydrochloric  acid  until  acid  to  litmus  paper,  then  add  ten  drops 
more  acid. 

Filter  and  evaporate  to  dryness  on  the  water  bath  with  a  piece  of 
turmeric  paper  partly  immersed  in  the  fluid. 

Cherry  red  colour  of  the  paper  is  positive  for  boric  acid  and  borax. 

The  colour  changes  to  a  bluish  green  by  a  drop  of  ammonia. 

A  quantitative  test  should  be  carried  out  because  boric  acid  occurs 
in  apples  and  other  fruits  and  vegetables  in  nature  in  minute  quantities. 
It  occurs  in  greater  quantities  in  common  salt. 


FOOD  579 

Sulplnirous  Acids  and  Sulphites. 

The  preservative  may  be  present  as  acid  sulphites  of  sodium  or 
calcium  or  as  sulphur  dioxide  gas  itself.  This  is  the  case  especially 
in  wines  or  molasses  where  the  acids  are  present  probably  partly  in 
combination  with  aldehydes  and  sugars. 

Weigh  50  grm.  of  sample  into  a  500  c.c.  flask. 

If  a  solid,  add  recently  boiled  water. 

Through  the  separatory  funnel  of  the  flask  add  5  to  10  c.c.  of  a 
20  per  cent,  solution  of  phosphoric  acid. 

Distil  by  steam  in  a  current  of  carbon  dioxide,  collecting  the  distil- 
late in  25  c.c.  of  saturated  bromine  water. 

Distil  about  150  c.c.  adding  a  little  more  bromine  water  if  necessary. 

After  distillation  is  complete  boil  off  the  excess  of  bromine. 

Dilute  the  solution  to  250  c.c. 

Add  5  c.c.  of  hydrochloric  acid. 

Heat  to  boiling. 

Add  very  slowly,  with  constant  stirring,  a  hot  10  per  cent,  solution 
of  barium  chloride,  until  in  slight  excess. 

Allow  to  stand  for  an  hour,  filter,  wash  with  hot  Avater,  ignite  and 
weigh  as  barium  sulphate. 

A  "  blank  "  experiment  should  be  done  without  any  of  the  sample 
in  the  flask  and  any  barium  sulphate  obtained  subtracted  from  the 
main  amount. 

A  special  work  should  be  consulted  for  this  more  technical  test  for 
which  special  apparatus  is  necessary. 

Fluorides. 

The  fluorides  of  sodium  and  ammonia  have  been  used  more 
especially  in  beer  and  malt  extracts. 

The  etching  of  glass  method  is  the  best  for  detection. 

See  a  special  work  for  this  more  technical  test. 

Saccharin. 

It  has  some  antiseptic  power  but  it  is  generally  employed  as  a 
sweetener.  The  continued  use  of  small  quantities,  say  of  0*3  grm.  per 
diem,  is  sufUcient  to  impair  the  digestion. 

Extract  wdth  ether  as  for  benzoic  acid. 

Evaporate  spontaneously  and  taste  the  residue. 

A  sweet  taste  is  positive  for  saccharin  to  20  mg.  per  litre. 

If  present  a  more  complicated  test  should  be  carried  out  to  get  rid 
of  any  "  false  saccharin  "  which  may  be  present. 

Copper  Sulphate. 

Make  an  ordinarv  watery  solution. 

Add  ammonium  sulphide. 

A  black  colour  is  positive  for  copper  sulphate  (and  lead). 

The  colour  is  not  discharged  by  acids. 


58o 


TROPICAL    HYGIENE,    SANITATION,    ETC. 


VEGETARIANISM. 

Nature  never  intended  that  man  should  be  strictly  vegetarian. 

In  herbivoruus  animals  the  aecum  is  very  much  larger  in  pro- 
portion than  man's,  in  order  to  accommodate  and  digest  the  bulk  of 
vegetable  matter  necessary.  In  man,  this  organ,  not  being  so 
necessary,  has  atrophied,  the  often  troublesome  appendix  being  a 
portion  of  the  atrophied  organ. 

The  gastric  and  intestinal  juices  of  man  are  intended  for  the 
digestion  of  meat  foods. 

Peas,  beans  and  lentils  are  amongst  the  most  nutritive  of  vegetable 
foods,  but  much  of  their  protein  is  undigestible.  The  cellulose  wall  of 
most  vegetable  cells  containing  about  20  per  cent,  of  protein  cannot 
be  digested  in  man  and  forms  the  large  residue  of  the  stools  of 
vegetable  feeders. 

Xuts  are  only  to  be  consumed  in  very  limited  quantities. 

Milk,  eggs  and  cheese  are  certainly  good  and  rich  in  protein  but 
thev  belong  to  the  animal  kingdom. 

It  is  true  that  less  meat  and  more  vegetable  foods  should  be  con- 
sumed b}'  Europeans  residing  in  the  tropics. 

INFANT  FEEDING  IN  THE  TROPICS. 

^^"hen  Nature's  provision  is  sufficient,  infant  feeding  is  simplicity 
itself.  It  is  with  the  artificial  feeding  of  white  babies  that  we  are  here 
concerned  and  that  in  countries  where  good  cow's  milk  is  rarely 
available. 

W.  E.  Deeks  has  studied  this  subject  at  Panama  and  gives  us  the 
results  of   his   experience    as   follows. 

Table  for  Infant  Feeding. 

T7  ,  Amount  of     Interval  of 

Pormula  u  r    j  i    j- 

each  feed  feeding 

Plain  boiled  water  two  or  three  times 
X.     y.     z. 

3     60     ...     i-i  oz.    ...     2    hours 


Age  of  infant 

1  day 

2  days 


!1 
)> 


3 

4 

5 
6 

7    ,.  

1-4  weeks     ... 

4  weeks  to  3  months 

3-6  months  ... 

6-9         .,       

9-12       ,,       


•3 
3 

3 
3 
3 
3 
3 


z. 

60 

5° 
40 

30 

24 
20 
16 
12 
12 
12 
12 


1  oz. 
i^  oz. 

2  oz. 

3-4  oz. 
5-7  oz. 
7-9  oz. 
8-iooz. 


2 
2 
2 
2 
2 

2 
2 

2i 
3 

3 

4 


No. 

of  diluent 

feeds  daily 

6-8 

boiled  water 

8 

)> 

10 

>> 

10 

>» 

—  10 

» 

—  10 

it 

8 

>i 

7-8 

!> 

7 

>) 

6 

barley  water 

S 

» 

Note  : 


X. 

y- 

z. 


equals  sweet  condensed  milk 

,,       unsweetened  condensed  milk 

,,       boiled  water,  or  after  six  months  of  age,  barley  water 


The  contents  of  every  bottle  should  be  tasted  first  by  the  mother  to 
see  that  no  alteration  has  taken  place  in  the  contents. 


FOOD  581 

A  proper  tubeless  feeding  buttle,  kept  scrupulously  clean,  is 
essential. 

To  make  the  barley  water  :  take  one  tablespoonful  of  pearl  barley 
and  wash  it. 

Add  one  pinl  of  cold  water. 

Soak  for  ten  to  tw^elve  hours  and  strain. 

Boil  slowly  for  two  hours. 

Add  water  from  time  to  time  so  as  'o  have  one  pint  of  the  finished 
product. 

Season  with  half  a  teaspoonful  of  salt  and  strain  through  muslin. 

To  make  oatmeal  jelly  :  — 

This  food  is  useful  after  the  child  is  nine  months  old  when  there 
is  a  tendency  to  constipation. 

Take  one  cupful  of  rolled  oats,  soak  in  two  cupfuls  of  water  for  ten 
to  twelve  hours,  and  strain  through  muslin. 

Add  one  cupful  of  cold  water. 

Boil  for  two  hours  and  stir  frequently. 

Add  half  a  teaspoonful  of  salt,  when  cool  a  jelly  is  formed. 

Add  two  to  four  teaspoonfuls  to  each  bottle. 

When  the  child  is  one  year  old  give  one  hen's  egg  daily  in  milk  or 
boiling  water  when  it  jellies.  Afterwards  thev  may  be  lightly  boiled 
and  given  with  a  rusk  or  toasted  bread  and  butter. 

The  child  should  not  have  more  than  five  feeds  daily. 

After  fifteen  months  old,  give  two  eggs  daily,  and  four  feeds  in  all. 

After  eighteen  months  old,  give  a  light  general  diet  with  a  little 
green  vegetable. 

After  twenty-four  months  old,  feed  thrice  daily  and  give  water  only 
between  meals. 

From  age  three  months  the  child  may  have  fresh  unsweetened  fruit 
juices. 

Sugar  is  usually  given  to  babies  in  excess  and  should  be  but  minute 
in  amount. 

The  majoritv  of  prepared  infant  foods  contain  a  large  carbohydrate 
content,  e.g.,  powdered  biscuit,  &c.  No  child's  digestive  juices  can 
deal  with  it  adequately  until  more  than  one  year  old.  If  the  child 
takes  too  much  of  it  there  will  be  fatness,  inactivity,  slow  dentition, 
constipation  and  occasional  diarrhoea.  Generally  such  foods  should  be 
avoided.     Probably  the  most  useful  of  all  are   Allenbury's. 

The  better  nourished  the  baby  the  less  disturbance  may  one  expect 
during  teething. 

If  there  is  vomiting,  absolute  anorexia,  high  fever  and  sometimes 
diarrhoea,  in  all  probabilitN-  milk  poisoning  is  the  cause. 

Examine  and  jealously  guard  the  milk  supply. 


582  TROPICAL    HYGIENE,    SANITATION,    ETC. 

Excess  of  sugar  and  other  carbohydrates  may  cause  :  — 

Fever,  enteritis,  entero-colitis,  eczema,  enuresis  and  rheumatisms, 
recurring  bronchitis,  pustular  dermatitis  and  dry  histreless  hair. 

Curds  in  the  stools  (fatty  acid  soaps)  are  not  important. 

Banana  flour  is  a  useful  food.  Add  one  ounce  (31  grm.)  to  one  pint 
of  water.     Boil  for  five  minutes. 

The  methods  here  advised  are  cheap,  sterile  and  efificacious  (W.  E. 
Deeks). 

CONCENTRATED  TABLET  FOODS. 

The  food  tablet  will  never  become  universally  used.  Science  will 
never  request  that  we  should  sit  down  to  a  lozenge  lunch  or  tablet  tea. 

Sugar  is  almost  essential  as  a  food  but  it  cannot  be  compressed. 

The  solids  of  our  normal  diet,  daily,  when  all  gases  and  water  have 
been  driven  off,  will  occupy  three-quarters  of  a  pint. 

If  we  take  this  in  5-grain  tablets  we  should  require  about  1,700 
dailv.  But  these  we  could  not  digest  without  water  and  six  pints 
would  be  required  for  these  tablets  only  and  water  cannot  be  com- 
pressed. The  question  of  taste,  smell,  &c.,  are  all  important  to 
stimulate  the  digestive  juices  to  flow. 

There  would  have  to  be  some  definite  w:ay  of  distinguishing  the 
itablets  to  know  when  one  was  about  to  partake  of  the  meat  or  pudding 
course. 

Some  dried  foods  can  be  prepared  and  are  useful,  as  evaporated 
milk,  casein,  &c. 

DRINKS. 

Water. 

There  is  nothing  to  equal  Nature's  first  thirst  quencher,  viz.  :  cool, 
pure  water.     Mankind,  however,  requires  variety. 

Tea. 

Tea  (Thea  sinensis,  &c.)  has  an  odour  due  to  essential  oil,  a  nerve 
stimulant  due  to  caffeine,  2  to  5  per  cent.,  and  an  astringent  due  to 
tannic  acid,  7  to  15  per  cent. 

Indian  and  Ceylon  teas  contain  about  twice  as  much  tannin  as  the 
China  teas,  and  tannin  is  prejudicial  to  digestion,  forming  with  proteins 
a  leathery  substance  which  is  insoluble. 

Strong  tea  or  an  excess  of  weak  tea  induces  indigestion,  nervous- 
ness and  irritability.  The  nervous  breakdown  of  tea-tasters  is  due  to 
this.     Tea  should  be  drunk  within  ten  minutes  of  its  being  made. 

Coffee . 

Coffea  arabica  contains  half  to  three-quarters  as  much  caffeine  as 
tea. 

Black   coffee   as   a    common    and    frequent    indulgence    produces   a 


FOOD  583 

deplorably   neurotic  state.     In  moderation   it  is  a  good  muscular  and 
mental  tonic.     Dyspeptic  persons  should  not  take  coffee  after  dinner. 
Chicory,   previously  considered  harmless,   is  now  said  to  have  an 
unfavourable  effect  upon  growth  and  development. 

Cocoa. 

Cocoa  (Theobroma  cacao)  powder,  commonly  known  as  cocoa 
"essence,"  is  pure  cocoa  deprived  of  part  of  its  fat,  which  originally 
amounts  to  50  per  cent,  or  more  of  the  whole.  This  fat  is  not  extracted 
when  the  cocoa  powder  is  to  be  used  for  chocolate.  For  this  latter 
sugar  and  flavourings  are  added,  and  the  whole  is  ground  in  a  hot 
mill.  Cocoa  powder  contains  27-33  per  cent,  of  fat,  12-15  P^r  cent, 
of  proteins,  of  which  60  per  cent,  is  not  assimilable.  There  are  also 
traces  of  caffeine.  In  pure  cocoa  nibs  there  is  o'9-2'7  per  cent,  theo- 
bromine. 

Cocoa  powder  forms  a  pleasing,  mildly  stimulating  beverage,  but 
is  not  a  food.     When  starches  are  added  cocoa  is  more  assimilable. 

Cocoa  contains  too  many  solids  for  it  to  be  a  good  solvent  of  other 
foods  when  they  are  taken  at  the  same  time.  It  is  estimated  that 
80-90  per  cent,  of  the  cocoa  bean  is  insoluble  in  water.  The  so-called 
soluble  cocoas  are  not  soluble,  but  potassium  carbonate  is  added,  which 
saponifies  some  of  the  fat  and  keeps  the  particles  longer  in  suspension. 
This  chemical  does  not  aid  the  digestion,  especially  of  invalids  and 
children. 

Alcohol. 

Alcohol  is  made  from  malted  and  unmalted  grain,  potatoes,  maize, 
rye,  grape,  beetroot,  molasses,  palm  tree  sap,  coal  and  coke  gases,  &c. 

The  total  effect  of  small  quantities  is  to  favour  gastric  digestion, 
but  excess  is  a  common  cause  of  acute  and  chronic  dyspepsia  and  many 
other  ailments.  Alcohol  is  a  source  of  heat  and  energy,  but  it  reduces 
the  activity  of  metabolism  and  stimulates,  but  later  depresses  the 
circulation  and  the  nervous  system  independently  of  its  action  on 
tissue  changes. 

It  is  not  a  food  because,  while  it  is  oxidizable,  it  acts  detrimentally 
on  the  nervous  tissues. 

Men  soon  get  thirsty  in  the  tropics,  and  excesses  seem  to  be  the 
rule.  Alcohol  is  not  generally  necessary  and  strenuous  work  can  be 
done  without  it.     Taken  medicinally  it  is  of  great  value. 

The  alcoholic  average  contents  of  common  drinks  are  :  — 

Whiskies             ...         ...  50 — 60  French  wines         ...         ...  8 — 11 

Brandies              ...         ...  45 — 65  British  wines          ...         ...  20 — 25 

Gin           35 — 45  Champagne             10 — 12 

Rum         ...  35 — 70  Beer             ...  3—5 

Koumiss  1-3  per  cent,  alcohol  is  made  from  mare's  or  cow's  milk. 
The   body    manufactures   about    two  ounces    (62    grm.)   of   alcohol 
37 


584  TROPICAL    HYGIENE,    SANITAl^ION,     ETC. 

daily,  or  an  amount  equal  to  that  contained  in  about  four  ounces  of 
whisky  or  brandy. 

Mineral  Waters. 

Soda  water  contains  little  or  no  soda  at  all,  but  carbon  dioxide  gas. 

It  is  useful  for  some  invalids. 

Lemonade  from  fresh  limes,  not  the  chemically  made  article,  is  a 
refreshing  beverage. 

Commercial  articles  contain  saccharin  which  has  a  sweet  taste,  but 
no  nutritive  value.  It  is  a  drug  and  not  a  food,  and  is  forbidden  in 
the  United  States  except  for  medicinal  purposes.  Sugar  is  not  desir- 
able as  a  substitute  in  these  instances  because  it  would  ferment. 

Saponin  is  a  hjemol^ytic  poison  which  is  used  in  drinks  and  should 
be  prohibited.     This  produces  the  "head  "  so  well  known  in  beers. 

Gum  arabic  could  be  substituted,  but  why  should  a  "  head  "  be 
required  at  all  ? 

Coal  tar  colouring  matters  are  sometimes  used,  some  of  which  are 
poisonous. 

SANITATION.  * 

REFUSE,   ITS   COLLECTION,   REMOVAL  AND   DISPOSAL. 

An  outline  only  of  this  subject  is  attempted  here. 

The  systems  to  be  adopted  vary  according  to  the  population,  the 
nature  of  the  surrounding  country  and  the  local  tribes  for  which 
provision  is  to  be  made. 

A  medical  ofificer  is  often  placed  where  there  is  no  legal  enforce- 
ment of  hygienic  measures,  and  he  must  adopt  that  system,  most 
hygienic,  which  the  particular  people  with  whom  he  has  to  deal  are 
prepared  to  use. 

All  waste  products  and  refuse  decompose  much  more  rapidly  in 
the  tropics,  and  must  be  removed  and  disposed  of  daily.  This  consists 
of  domestic  refuse,  human  excreta,  solid  and  liquid,  slop  water,  animal 
excreta  and  waste. 

In  large  towns  sewers  are  in  existence  for  dealing  with  human 
excreta,  but  in  villages  and  small  towns  manual  labour  is  required  for 
its  removal  and  disposal. 

The  amount  to  be  removed  is  one  and  a  half  times  as  much  for 
tropical  natives  as  for  Europeans,  the  latter  being  largelv  meat  eaters 
and  the  former  vegetable  feeders.  For  each  vegetable  feeder  one  could 
estimate  as  a  maximum  8  ounces  (225  grm.)  of  solids  and  40  ounces 
(ri2  litres)  of  liquid  excreta  per  man  per  diem,  or  if  ablution  water  is 
to  be  included  80  ounces  (2*25  litres)  of  liquids.  Hence  for  1,000 
people  there  would  be  500  lb.  (226  k.)  of  solids  and  500  gallons 
(2"268  litres)  of  liquids  to  be  removed  daily. 


SANITATION  585 

Now  1,000  ounces  of  solids  equal  i  cubic  foot,  and  6*25  gallons 
of  fluids  equal  i  cubic  foot. 

One  adult  yields  14  cubic  feet  of  solids  and  liquids  per  annum 
without  ablution  water.  If  the  latter  is  added  it  is  best  to  double  the 
amount  given  above,  then  one  can  ascertain  the  amount  of  land 
necessary  for  its  disposal. 

For  its  removal  use  buckets  of  i   cubic  foot  capacity  and  carts  of 

12  cubic  feet  capacity. 

Now  1,000  persons  yield  per  diem  500  lb.  of  solids  or    SQ'^  ^  i^    or 

1. 000 

8  cubic  feet  of  solids  and  also  500  gallons  or  J^?  or  80  cubic  feet.     This 

6-25 

equals  eight\'-eight  buckets  daily.  Now  each  scavenger  carries  two 
buckets  and  goes  twice  daily  to  the  trenching  ground,  hence  to  remove 
the  total  excreta  of  1,000  persons  there  would  be  required  twenty-two 
men  with  forty-four  buckets  of  i  cubic  foot  capacity  each.  Each  man 
to  make  two  trips  daily. 

LATRINES. 

(A)  For  Natives. 

(i)  The  Bush. — All  primitive  natives  in  small  communities 
use  the  bush.  If  a  small  hole  is  made  in  the  ground  and 
the  excreta  covered,  the  method  would  be  hygienic  for 
districts  where  there  are  small  communities  and  extensive 
bush  abounds. 

(2)  Pits. — Some   natives   dig  pits  about   2-6   metres   deep  and 

2-4  metres  in  diameter;  the  sizes  are  by  no  means  con- 
stant. These  holes  are  covered  over  with  sticks  and  clay, 
leaving  a  small  aperture  at  the  top.  When  one  is  nearly 
full  it  is  covered  with  earth  and  another  prepared.  It  is 
surprising  what  a  minimum  amount  of  nuisance  such  pits 
cause. 

(3)  Shallozv  Trenches. — These  are  useful  in  certain  small  bush 

communities  where  there  is  ample  supervision.  An  area 
is  screened  off  and  divided  for  the  sexes.  The  trenches 
are  half  a  metre  deep  and  a  quarter  of  a  metre  wide. 
They  are  made  as  long  as  required.  The  native  squats 
astride.  Earth  is  thrown  on  daily,  and  the  whole  trench 
is  filled  in  when  it  is  within  a  short  distance  from  the 
top.  A  fresh  trench  is  then  prepared  in  front  of  the  old 
one,  and  so  on  until  the  whole  screened  area,  is  exhausted. 
The  screens  are  then  removed  to  another  part.  In  some 
instances  the  excreta  is  mixed  with  earth  and  removed 
daily. 


586 


TROPICAL    HYGIENE,    SANITATION,    ETC. 


(4)  Deep    Trenches. — These  are  often   used,   but  are  very  un- 

satisfactory and  should  be  condemned.  They  are  3-4 
metres  deep,  1-2  metres  wide,  with  sticks  thrown  across 
at  intervals.     The  sides  are  nearly  always  fouled. 

(5)  Prepared  Trenches. — These  are  useful  in  certain  instances 

close  to  works  for  the  use  of  the  native  workmen.  The 
floor  of  the  latrine  is  covered  over  with  dry  earth,  the 
excreta  covered  with  another  layer  immediately,  and  the 
whole  removed  daily.     Constant  attendants  are  required. 


A  double  public  latrine. 

Exposure  to  the  sun  is  advantageous,  but  rain  and  flood 
water  must  be  excluded  in  the  rainy  season. 

(6)  River  Latrines. — These  are   often   used   by   companies   for 

their  employees,  but  the  practice  fouls  the  river  banks 
and  the  river  bed  at  low  water,  and  in  any  case  pollutes 
the  water  for  the  villages  downstream.  The  practice 
should  be  condemned. 

(7)  Deep  Pit  Latrines. — For  better  class  natives  one  has  found 

useful  a  latrine  as  follows  :  A  hole  is  dug  about  6 
metres  deep  and  0*5  by  075  metres  in  diameter.  A  box 
seat  is  fixed  over  it  with  a  lid  to  make  it  fly-proof.  A 
small  house  with  a  locked  door  is  built  over  this,  say  of 
corrugated  iron  and  made  movable. 


SANITATION  587 

A  small  portion  of  earth  is  thrown  doAvn  daily  from  a  box 
of  loam  kept  in  the  little  house  for  the  purpose.  A 
latrine  like  this  may  last  a  family  for  a  year  or  more, 
after  which  time  it  is  filled  in,  another  hole  dug,  and 
the  house  removed  over  it.  This  method  can  only  be 
adopted  where  there  are  small  communities,  and  where 
there  can  be  no  possibilit}^  of  drainage  affecting  the  water 
supply.  Flies  do  not  descend  deeply  to  breed.  There 
is  no  nuisance  with  latrines  of  this  kind  when  kept 
properly. 
(8)  Chinese  Latrines. — Men  use  public  latrines;  the  women  and 
children  use  vases  and  pots  in  the  house,  which  are 
emptied  dailv.  The  public  latrines  may  be  platforms 
over  fish  ponds  or  raised  masonry  reservoirs  with  holes 
over  which  the  user  squats.  The  use  of  petroleum  will 
remove  all  objections  to  these  masonry  latrines,  and  they 
are  useful. 

These  can  be  made  elaborate  and  the  system  applied  to 
private  dwellings.  It  is  always  much  better  to  use  pails 
beneath  holes  so  that  the  excreta  can  be  removed  daily 
from  outside  the  house.  The  floor  and  sides  of  the  recess 
for  the  pail  should  be  cemented.  The  buckets  should 
have  a  special  lid  to  prevent  splashing. 

A  double  number  of  pails  is  required  to  replace  those 
removed.  The  pails  should  be  washed  out  with  cyllin 
before  being  replaced. 

Some  of  these  latrines  are  modified  so  as  to  separate  the 
solid  from  the  fluid  excreta.  The  former  can  be  applied 
to  the  land,  and  is  of  more  value  than  the  fluids.  When 
they  are  not  separated  decomposition  sets  in  more  rapidly 
and  gives  rise  to  liberated  ammonia,  carburetted  hydrogen 
and  foetid  organic  gases.  The  solid  matter  is  mixed  with 
•earth,  the  urine  passing  down  an  inclined  plane  in  front 
of  it  and  treated  separately,  but  in  the  same  way. 

The  solids  are  removed,  deposited  in  pits  on  the  farms, 
covered  with  earth,  kept  three  to  six  months,  and  then 
used  upon  the  land. 

The  urine  is  used  for  manuring  soon  after  collection. 
The  Chinese  are  the  most  careful  people  in  the  world  in  the 
conservation  and  profitable  disposal  of  sewage,   and  the 
most  careless  with  regard  to  personal  cleanliness. 

Solid  excreta  is  often  used  in  the  production  of  silkworms 
by  applying  it  to  the  mulberry  trees  and  also  for  breeding 
maggots  for  the  fattening  of  ducks. 


588  TROPICAL    HYGIENE,    SANITATION,    ETC. 

(9)  Indian  Latrines. — The  separation  system  is  commonly 
used.  The  urine  and  washings  are  led  by  a  pipe  to  a 
special  receptacle  and  are  not  immediately  mixed  with 
earth.  There  are  many  modifications  of  platforms  both 
Avith  regard  to  material  and  pattern.  They  are  made  in 
iron,  stonework,  glazed  ware,  &c.,  and  may  be  so  con- 
structed as  to  avoid  splashing.  Instead  of  a  seat  there 
are  the  necessary  foot  rests  for  squatters  such  as  are 
employed  in  all  oriental  latrines.  Pails  for  the  removal 
of  the  excreta  should  have  a  tight,  well-fitting  lid.  They 
are  taken  away  in  carts  or  carried  by  coolies.  Their 
contents  should  not  be  emptied  into  carts  near  to 
dwellings. 
(B)  European. 

(i)  Deep  Pit  Latrines. — These  are  useful  for  small  communi- 
ties, with  a  box  seat  over  a  pit,  and  a  small  movable  house 
over  the  whole  as  previously  described. 

(2)  The  Bucket  System. — This  is  good  when  the  natives  attend-' 

ing  to  them  are  reliable  and  the  supervision  sufficient. 
Loam  should  be  used  and  the  bucket  emptied  daily  and 
washed  out  with  cyllin.  No  nuisance  need  arise.  The 
receptacle  for  the  bucket  should  be  so  constructed  that  it 
is  not  necessary  for  the  scavengers  to  enter  the  dwellings. 

(3)  Water   Closets. — These  are  the  best  of  all   where  a  water 

supply  is  laid  on  and  the  drainage  is  good.  They  should 
be  outside  the  house,  as  in  the  tropics  the  evaporation  of 
water  allows  the  best  of  traps  to  leak  sewer  gas. 

(4)  A   Che7nical  Method. — For  troops  in  the  field  the  system 

suggested    by    Myer    Coplans    and    James    Menzies    has 
found  favour  with  the  War  Office,  and  is  useful  for  the 
purpose  for  which   it  is  intended.     The  writers  describe 
it  as  follows  :  — 
"The  apparatus  consists  of:  — 

"  (i)  A  partitioned  chamber  for  reception  of  excreta, 

"  (2)  A  condenser, 

"  (3)  A  receptacle  for  the  condensed  products. 
"  The  tank  into  which  the  excreta,  mixed  urine  and 
faeces  are  introduced  is  cylindrical  in  shape  and  divided 
into  several  sections  by  horizontal  partitions.  The 
sewage  is  poured  in  through  a  hopper  and  broken  up  by 
a  revolving  comb ;  it  passes  on  from  above  downwards 
through  the  successive  partitions,  being  exposed  all  the 
time  to  a  high  temperature.  As  a  result  there  ensues 
complete  disintegration.     The  solid  residue  comes  out  at 


SANITATION  589 

the    bottom     carbonized     into    charcoal  ;     the    volalihzed 
products  are  led  through  a  condenser  and  received  into  a 
chamber,  where  they  settle  out  into  :  — 
"  (i)  A  heavy  ammoniacal  liquor, 
"  (2)  A  layer  of  oil, 
"  (3)  Gaseous  products. 

"  These  last  are  piped  off  to  a  burner,  where  their  com- 
bustion provides  the  heat  required  to  produce  the  dis- 
integrating action  on  the  sewage  that  takes  place  in  the 
partitioned  chamber. 

"  The  ammoniacal  liquor  forming  the  lowest  laver  in  the 
receiver  contains  pyridine  bases,  which  are  of  value  as 
an  insecticide  and  as  a  bactericide.  The  laver  of  oil  is 
collected  and  used  for  working  the  motor  that  actuates 
the  revolving  comb  or  scraper  in  the  cvlinder  first  men- 
tioned. The  solid  carbonized  residue  is  practically  pure 
carbon,  which  may  be  used  as  fuel  or  for  many  other 
purposes.  Hence  these  excretory  products  can  be  ren- 
dered innocuous  and  disposed  of  at  a  very  minimum  of 
cost,  or  even  at  no  cost  at  all ;  it  is  quite  possible  that  the 
residue  charcoal  may  come  to  be  a  source  of  profit.  At 
any  rate,  it  seems  proved  that  the  working  expenses  are 
covered.  The  fact  of  the  apparatus  being  self-contained 
and  self-supporting — viz.  :  (i)  That  the  heat  required  for 
the  destructive  distillation  of  the  excreta  is  provided  by 
the  gas  which  is  set  free;  (2)  that  the  petroleum  oil  for 
running  the  motor  is  also  obtained  from  the  results  of 
the  same  distillation — distinguishes  it  from  all  other 
chemical  processes  or  methods  of  disinfection  depending 
on  heat. 

"  It  is  stated  that  no  fuel  is  required  at  all  except  for  the 
commencement  of  the  working.  That  an  insecticide  and 
a  bactericide  should  be  obtainable  from  the  condensation 
liquor  is  also  much  in  favour  of  this  method,  if  in  practice 
it  can  be  recovered  without  difficulty.  In  camp  life  such 
a  substance  would  be  most  useful  for  the  destruction  of 
flies,  fleas  and  vermin  generally,  as  well  as  for  its  more 
important  disinfectant  applications  to  contagious  patho- 
genic material." 

Cesspools. 

Cesspools  or  receptive  tanks  for  houses  or  blocks  of  buildings  are 
generally  difficult  to  keep  clean  and  to  emptv. 

To  correct  these  nuisances  several  methods  of  emptying  cesspools 


590  TROPICAL  HYGIENE,   SANITATION,   ETC. 

have  been  adopted,   the  most  recent  being  the   "  Tonne  Vidangeuse 
Pneumatique,"  but  it  is  a  costly  method. 

No  town  with  a  population  of  over  15,000  can  deal  efficiently  with 
its  excreta  other  than  by  a  pipe-water  system. 

The  Disposal  of  Excreta. 

Apart  from  what  has  already  been  said  generally  on  this  subject 
one  may  include  the  following  remarks:  — 

(i)  Excreta  may  be  collected  into  cesspools  and  pits  and  then  used 
for  agricultural  purposes  on  farms  as  previously  stated. 

(2)  It  may  be  carried  to  an  incinerator  and  destroyed  completely, 

but  such  is  regarded  generally  as  being  a  needless  waste. 

(3)  It  can  be  carried  by  a  water-carriage  system  in  the  case  of  larger 

towns  and  discharged  into  large  rivers,  or  by  a  pipe  out  to 
sea.  The  failings  of  the  latter  system  are  waste,  offensive 
odours  and  troubles  from  the  ebb  tide. 

(4)  After  a  water-carriage  system  it  can  be  treated  by  precipitation 

.with  or  without  filtration,  intermittent  filtration  through  land, 
broad  irrigation,  or  bacterial  treatment.  Special  works  should 
be  consulted  for  technical  details.  The  principles  have  been 
dealt  with  under  Water  Purification. 

(5)  Chemical    processes   are    used    apart    from    the    one    mentioned 

above  proposed  by  Coplane  and   Menzies. 

The  "  Poudrette  "  method  is  fairly  well  known. 

After  fermentation  by  urea,  volatile  ammonium  carbonate  is 
formed  which  is  usually  fixed  with  calcium  sulphate.  The 
sewage  is  then  desiccated  by  evaporation  in  numerous  shallow 
pans. 

The  resulting  powder  is  known  as  "  Poudrette,"  and  is  sold 
to  farmers  for  manure.  The  process  is  costly  and  the  demand 
is  usually  small.  Two  tons  of  excreta  yield  about  two 
hundredweight  of  poudrette.  The  system  is  unsuitable  where 
there  is  much  rain.  There  are  various  modifications  of  this 
system. 

(6)  Trenching  and  cultivation  are  perhaps  the  methods  most  com- 

monly employed  in  hot  climates.  The  trenching  ground  must 
be  high,  well  drained,  with  a  loamy  soil,  to  the  leeward  of 
the  village  or  town,  and  well  screened  from  the  public  view. 
The  area  should  be  large  enough  to  deal  with  all  excreta  from 
the  population  and  divided  into  twelve  monthly  plots  for 
trenching.  Tiie  trenches  should  be  o'6  metre  wide  and 
o'4  metre  deep.  They  should  be  0*3  metre  apart.  Each 
trench  should  receive  o'2  metre  of  excreta.  The  area  required 
for  a  population  of  1,000  persons  would  be  14  square  metres 


SANITATION 


591 


per  diem,  or  for  the  same  number  5,110  square  metres  per 
annum.  This  affords  twelve  months'  rest  for  each  trench. 
Where  the  soil  and  all  conditions  are  particularly  favourable 


Disposal  of  Excrement  as  Manure.     Chinese  Method. 


(l)  Chinaman  taking  from  public  latrines 
in  a  Government  receptacle  fresh  human 
ordure. 


(3)  Filling  his  private  bucket  with  the 
contents  of  manure  pit,  consisting  in  part  of 
fa;ces  kept  sufficiently  long  for  eggs  to  be 
destroyed,  but  in  part  sufficiently  fresh  for 
eggs  to  retain  their  vitality.  To  the  contents 
of  this  bucket  water  is  usually  added. 


(2)  Decanting  into  his  manure  pit  where, 
if  kept  long  enough,  the  eggs  of  most  entozoa 
will    be   destroyed.     It   is    rarely    kept    long 


enouiih. 


(4)  Watering  vegetables,  including  those 
used  for  salads  or  eaten  raw,  with  the  contents 
of  this  bucket.  The  great  prevalence  of 
"  flukes  "  (trematoda)  amongst  the  Chinese 
is  probably  due  to  the  general  use  of  some 
such  method. 


the  land  can  be  retrenched  in  six  months.  It  is  al^va^•s  best 
to  arrange  it  so  that  one  trench  takes  one  day's  supplv,  thirty- 
one  trenches  for  a  month's  supply.  The  earth  should  be 
raised  dome-shaped  when  covering  them  in  to  allow  for 
sinking. 


592  TROPICAL  HVGIEXE,   SANITATION,   ETC. 

After  three  months  plough  up  each  plot  and  sow  with  rye  grass, 
sugar  cane,  or  tobacco.     After  the  first  crop,  vegetables  can 
be  grown  and  sent  to  the  market  for  sale  and  consumption. 
Swarms   of  flies  about   a   trenching  ground   indicate   improper 

management. 
Such  trenches  could  be  dug  at  the  base  of  cocoanut   or  palm 
trees,  a  safe,  effective  and  profitable  means  of  disposal. 
S ullage  water  should  be  taken  to  trenching  grounds  in  special  slop 
carts  where  there  are  no  good  drains. 

Storm  water  requires  surface  drainage. 
Wells  must  be  protected  and  sewage  controlled. 
Dry  Refuse. — This  always  exists  in  large  quantities. 
In  Calcutta,  with  its  population  of  three-quarters  of  a  million,  there 
are  nearly   1,500  tons  daily.     There  are  900  carts   employed  making 
three  trips  daily. 

For  disposal  incineration  is  always  the  best. 

Failing  this,  hollows  can  be  filled  up,  covered  with  soil  and 
planted,  but  the  system  is  not  to  be  recommended.  It  should  not  be 
thrown  into  ponds  or  marshes.  The  putrefaction,  fermentation  and 
formation  of  gases  thus  produced  will  go  on  for  years  and  mav  escape, 
proving  deadly  to  man  and  beast  alike,  even  though  the  refuse  mav  be 
covered  with  several  feet  of  earth. 

DISINFECTION. 

Disinfection  is  the  destruction  of  the  specific  virus  and  is  equivalent 
to  a  bactericide.  The  term  should  not  be  applied  in  a  general  manner 
to  antiseptics  which  arrest  or  impede  the  growth  of  organisms.  Dis- 
infection means  destruction  of  the  agents  of  infection. 

Deodorants,  of  course,  only  oxidize  and  destroy  or  mask  the  effluvia. 

Much  money  is  wasted  in  the  purchase  of  disinfectants,  while  the 
inefficient  application  of  them  engenders  a  false  feeling  of  security  and 
often  prevents  simple  means  of  purification. 

Whenever  possible  one  should  employ  a  simple  and  useful  method, 
namely,  of  exposing  articles  to  direct  sunlight,  or  rather,  to  the  ultra- 
violet rays  of  white  sunlight.  This  is  sufificient  to  destroy  ultimately 
most  pathogenic  organisms.    Desiccation  only  will  kill  cholera  vibrios. 

Disinfection  by  heat  or  chemicals  should  always  be  preceded  by 
thorough  cleansing,  e.g.,  stripping  the  paper  from  the  walls,  scraping 
and  washing  the  walls  and  floors,  allowing  plenty  of  air  and  as  much 
sun  as  possible  to  enter  the  apartments,  washing,  brushing,  beating 
and  suspending  all  garments,  blankets,  &c. 

The  chief  means  of  disinfection  are  heat,  hot  air,  steam  and 
chemicals. 


SANITATION  593 

Heat. 

This  is  the  most  efficient  means  of  disinfection,  but  unfortunately 
it  is  not  of  universal  application.  For  example,  infected  garments^ 
articles  of  small  value,  native  huts,  &c.,  should  be  destroyed  com- 
pletely by  fire,  and  in  the  latter  case  killing  all  the  rats  as  thev  attempt 
to  escape. 

Hot  Air. 

This  is  sometimes  used  for  clothes  and  bedding,  but  it  is  slow  and 
not  very  efficacious  owing  to  the  poor  penetrating  power  of  dry  heat. 
Some  articles  may  be  scorched.  It  is  useful  for  books  and  leather 
goods.  The  air  temperature  should  be  230^-250°  C.  for  four  to  eight 
hours,  but  steam  should  be  substituted  wherever  possible. 

Steam. 

Steam  is  more  rapid  and  efficacious  because  of  its  increased  pene- 
trating power.  The  essentials  of  its  application  are  that  the  steam 
under  pressure  shall  permeate  the  whole  article  to  be  disinfected.  The 
steam  temperature  must  be  221°  to  270°  C.  After  the  steaming,  hot 
dry  air  should  be  passed  through  the  articles  for  drying  them. 

Steam  is  inadmissible  for  leather  objects,  such  being  destroyed  by  it. 

All  fusible  substances  such  as  glue  and  sealing  wax  are  ruined  by 
steam  in  any  form. 

The  Current  Steam  Disinfector  is  the  best.  The  machine  is  light,, 
has  no  heavy  boiler,  is  of  easy  construction,  the  cost  is  low  and  the 
management  of  it  is  not  expensive. 

The  Washington  Lyon  apparatus  by  Manlove  and  Alliott  is  good. 
It  has  doors  at  both  ends.  The  steam  in  the  jacket  is  at  a  pressure 
of  30  lb.  to  the  square  inch  and  in  the  chambers  at  20  lb.  It  is  not 
superheated. 

Elliott  and  Paton's  vacuum  apparatus  is  an  improvement  owing  to 
the  greater  penetrating  power  and  its  increased  efficiencv  and  rapidity. 
Ten  to  twelve  minutes  will  suffice  for  the  disinfection.  The  articles  are 
dried  in  a  current  of  hot  air. 

Thresh's  Disinfector  has  been  extremely  useful  in  the  colonies  and 
the  tropics. 

Chemical. 

The  chemical  disinfectants  used  are  legion.  The  most  common 
are:  Corrosive  sublimate,  i  in  1,000;  Cyllin,  i  in  200;  Izal,  i  in  100 ; 
Carbolic  acid,  i  in  20 ;  Potassium  permanganate  and  Lysol. 

A  good  chemical  disinfectant  should  have  the  following  characters  : 

(i)  Germicidal  within  a  reasonable  time. 

(2)  Its  chemical  properties  should  not  unfit  it  for  ordinary  use. 


594  TROPICAL  HYGIENE,   SANITATION,   ETC. 

(3)  It  should  be  soluble  and  emulsible  in  water. 

(4)  It  should   not  produce  injurious  effects  on  human  tissue. 

(5)  It  should  not  be  too  costly  in  proportion  to  its  germicidal  value. 

(6)  Heating  "should  not  affect  it. 

Corrosive  sublimate  is  poisonous,  acts  on  metals,  is  thrown  out  of 
solution  by  alkalies  and  organic  matter,  is  acted  on  by  oxides,  sulphur 
and  sulphuretted  hydrogen,  loses  its  efficiency  when  mixed  with 
sputum,  faeces,  &c.,  because  a  harmless  albuminate  of  mercury  is 
formed.  Its  use  is  therefore  limited.  It  is  usually  mixed  with  other 
chemicals  to  overcome  some  of  these  difficulties. 

Carbolic  acid  is  not  so  widely  used  as  in  former  times  because  its 
bactericidal  power  is  sixteen  times  less  than  cyllin  and  kindred  prepara- 
tions. 

Cyllin,  lysol  and  similar  preparations  have  the  advantages  of  form- 
ing a  permanent  emulsion  with  water,  they  do  not  act  on  metals,  they 
are  less  toxic  than  carbolic  acid  and  are  sixteen  times  stronger  than 
carbolic  acid.  They  are  compatible  with  soap.  They  should  not  be 
mixed  with  anything  markedly  acid. 

Lysol  and  cyllin  are  the  routine  disinfectants  used  by  the  author. 

The  former  gives  a  clear  solution  for  instruments,  &c.,  for  opera- 
tions, the  latter  being  used  for  general  sanitary  purposes. 

For  general  use  one  may  use  the  following  :  — 

For  washing  drains,  courtyards,  &c.,  pot.  perman.,  i  in  250; 
cyllin,  I  in  200. 

For  disinfecting  walls,  floors,  furniture  and  clothing,  cyllin,  ij  oz. 
in  a  three-gallon  bucket,  or  lysol,  i  in  40. 

For  cowshed  floors,  dung-heaps,  privies,  cesspools,  dust-bins,  use 
the  above  but  double  strength. 

For  solid  and  liquid  excreta  use  as  above  or  chloride  of  lime,  4  per 
cent. 

For  oxidizing  organic  matter  in  water,  pot.  perman.  until  a  pink 
colour  remains. 

For  douches,  ]  per  cent,  lysol. 

For  hand  lotions,   i  per  cent,  solution  of  lysol. 

For  surgical  instruments,  i  per  cent,  lysol. 

For  Insecticides  Castellani  recommends  :  — 

For  body  lice,  kerosene,  vaseline,  guaiacol,  anise  preparations,  iodo- 
form, lysol,  cyllin,  carbol  solution,  naphthaline,  camphor  in  the  order 
mentioned  for  efficiency.  Sulphur,  corrosive  sublimate  and  zinc  sul- 
phate are  useless. 

For  bed  bugs,  kerosene,  guaiacol  and  pyrethrum. 

For  moths,  naphthalene,  menthol  powder.  The  latter  is  repellent 
to  lice,  fleas  and  mosquitoes. 

For  patients  entering  the  hospital  with  lice,  &c.  :  strip  off  all  clothes. 


SANITATION  595 

sterilize  clothes,  shave  patient  completely,  bath  in  soft  soap  each  night 
for  three  nights,  put  powdered  naphthaline  down  the  shirt  collar  next 
to  the  skin.  The  heat  at  night  will  dissolve  it  and  kill  any  remaining 
bugs. 

For  houses  and  dosed  spaces  fumigatiofi  is  usually  resorted  to. 

The  means  used  are  usually  sulphur  dioxide  and  sulphurous  acid 
gas,  formaldehyde,  chlorine  gas,  bromine  gas  and  nitrous  acid. 

(i)  Sulphur  Anhydride  and  Sulphurous  Acid  Gas. 

This  is  generated  by  burning  rolls  of  sulphur  in  an  iron  vessel  with 
a  little  spirit  to  commence  the  burning.' 

Three  pounds  of  sulphur  are  used  for  each  1,000  cubic  feet  of  closed 
air-space  yielding  theoretically  I'l  to  s'3  pcr  cent,  of  sulphurous  acid 
gas  in  the  space. 

The  Clayton  apparatus  is  in  common  use  for  extensive  fumigations 
with  this  gas.  As  in  other  methods  the  essential  factors  are  to  stop  up 
completely  all  the  air  holes  in  the  place  to  be  disinfected.  It  is  useful 
for  large  rooms,  stores,  ships,  &c. 

Three  per  cent,  of  this  gas  for  two  hours  will  kill  anv  pathogenic 
bacteria  in  exposed  spaces,  also  rats,  mice,  insects,  weevils,  beetles, 
cockroaches,  lice,  bugs,  moscjuitoes,  the  eggs  and  the  larvae  of  insects. 
Anthrax  spores  are  not  destroyed. 

Air  saturated  with  from  6  to  8  per  cent,  of  the  gas  for  six  hours 
destroys  :  — 

The  bacillus  of  plague,  diphtheria,  cholera,  typhoid  bacillus, 
tubercle  bacillus,  the  smallpox  infective  agent  and  vaccines. 

For  a  loaded  ship's  hold  use  3  per  cent,  for  eight  to  twelve  hours 
and  leave  closed  until  next  day.  0*5  per  cent,  will  kill  rats  and  insects 
in  two  hours  but  the  3  per  cent,  is  needed  for  the  penetration. 

The  gas  destroys  fruits  and  potatoes.  It  injures  wheat  in  bags 
but  not  in  bulk,  neither  maize,  rice,  nor  other  grains  in  bulk.  It  will 
kill  the  weevils  in  these. 

The  method  is  more  applicable  for  houses  than  any  other  because 
the  articles  need  not  be  removed  from  the  house.  It  is  easier  to  take 
,a  Clavton  apparatus  to  the  house  than  to  take  the  articles  to  the  dis- 
infector.     Everything  is  disinfected  in  situ. 

(2)  Formic  Aldehyde. 

Formic  aldehyde  vapour  by  the  alformant  lamp  is  good.  It  burns 
30  tablets  per  1,000  cubic  feet.     The  exposure  is  for  five  to  ten  hours. 

Trillat's  autoclave  for  formalin  is  more  efficient  but  much  more 
costly. 

Singer's  apparatus  uses  formalin  30  per  cent,  with  glycerine  10  per 
cent.  This  is  vaporized  and  is  ejected  as  a  fine  spray.  One  needs 
20  ounces  of  formalin  for  each  1,000  cubic  feet,  i  per  cent,  of  vapour 
or  o'5  per  cent,  solution  will  kill  most  organisms.     It  is  more  rapid. 


596  TROPICAL  HYGIENE,   SANITATION,   ETC. 

penetrating  and  diffusible  than  chlorine.     It  is  harmless  to  colour  but 
iron  is  affected. 

Other  means  of  using  formalin  are  as  follows  :  — 

Mix   I42i  grammes  of  permanganate 
285  ,,  formalin 

Put  it  in  a  metal  tray  7  inches  square  and  3-4  inches  deep  for  the  combustion 

The  Formanganate  process  consists  of  :  — 

16  oz.  of  40  per  cent,  formaldehyde  solution 
240  grammes  of  permanganate  for  each  1,000  cubic  feet 
Warmth  to  63''  F.,  and  moisture  to  60-65  per  cent,  humidity  are  essential. 
A  "  homely  "  method  is  to  use  8oz.  of  permanganate  for  each  pint  of  formaldehyde 
for  every  1,000  cubic  feet  of  air  space.     Suspend  wet  sheets  in    the  room.     All  fires 
should  be  extinguished  as  the  gas  is  slightly  inflammable. 

(3)  Chlorine. 

Chlorine  is  produced  by  adding  crude  hydrochloric  acid  to  calcium 
chloride,  ij  to  2  pints  of  the  acid  to  each  pound  of  lime.  Two  pounds 
of  calcium  chloride  with  three  pounds  of  the  acid  for  each  1,000  cubic 
feet  are  generally  used. 

Nitrous  fumes  are  generated  by  adding  copper  filings  to  nitric 
acid. 

Some  medical  officers  have  found  useful  the  following  for  the 
destruction  of  mosquitoes  :  — 

Crenyl  or  creolin  vaporized  by  a  spirit  lamp. 

Use  600  c.c.  for  a  room  of  100  cubic  metres  with  270  c.c.  of  alcohol. 

It  is  not  necessary  to  paste  up  all  the  cracks. 

It  should  be  left  for  eight  hours. 

It  is  cheap,  there  is  no  smoke,  it  does  not  damage  objects  and  does 
not  have  the  bleaching  effect  of  sulphurous  acid. 

In  Great  Britian  rats  do  an  enormous  amount  of  damage  reaching 
the  sum  of  ;^' 10,000,000  per  annum. 

For  rat  extermination  viruses  are  sometimes  used,  e.g.,  the  Liver- 
pool virus,  the  Danysz  virus  and  Ratin  at  a  comparative  cost  of  i,  iJ 
and  2^,  but  they  rapidly  lose  their  virulence  in  the  tropics. 

Barium  carbonate,  i  in  4  of  meal  on  fish  or  bread,  is  effective 
against  rats  and  mice. 

Warehouses  and  stores  should  be  disinfected  with  Clayton's 
apparatus  every  two  months. 

QUARANTINE. 

Land  quarantine  was  abolished  in  Europe  some  time  ago  but  the 
governments  have  the  right  to  close  the  frontiers  if  necessary. 

The  International  Regulations  of  the  Paris  Convention  of  1903 
were  formed  to  prevent  the  importation  of  cholera,  plague  and  yellow 
fever. 

These  are  the  onlv  diseases  as  vet  under  international  control. 


SANITATION  597 

For  large  seaports  the  Convention  recommends  as  follows  :  — 

(i)  A    properly    organized    port    medical    service    and    permanent 

medical  supervision  of  the  health  of  the  crews  and  of  the  population  of 

the  port. 

(2)  Suitable  accommodation  for  the  isolation  of  the  sick  and  for 
keeping  suspected  persons  under  observation. 

(3)  A  bacterial  laboratory  and  buildings  with  the  necessary  plant 
for  efficient  disinfection. 

A  supply  of  drinking  water  of  quality  above  suspicion  at  the  dis- 
posal of  the  port  authorities  and  a  system  of  scavenging  that  offers 
sufficient  guarantee  for  the  removal  and  disposal  of  excrement  and 
refuse. 

.4//  arriving  ships  arc  classified  as  :  — 

(i)  Infected  when  there  is  a  case  of  plague  or  cholera  on  board  or 
has  been  on  board  within  seven  days  of  arrival  in  port. 

The  sick  are  immediately  disembarked  and  isolated.  The  other 
persons  disembarked,  and  if  cholera  they  are  kept  under  observation 
either  on  a  ship  or  at  a  sanitary  station  before  being  allowed  "free 
pratique";  or  they  may  be  placed  under  *' surveillance  "for  five  days 
after  arrival  in  port.  Such  as  have  "free  pratique"  are  watched  by 
the  local  authorities  in  the  districts  where  they  go.  With  regard  to 
the  ship  the  bilge  water  and  drinking  water  are  replaced. 

If  it  is  a  case  of  plague  observation  may  be  followed  by  surveillance 
for  five  days.  The  soiled  linen,  wearing  apparel  and  personal  effects 
of   crew   and   passengers  are   disinfected   by   the   sanitary   authorities. 

Parts  of  the  ship  are  also  disinfected.  All  rats  must  be  destroyed 
within  forty-eight  hours. 

(2)  Suspected  when  there  has  been  a  case  of  plague  or  cholera  on 
board  at  the  time  of  departure  from  port  or  during  the  voyage,  but 
when  there  has  not  been  a  new  case  within  seven  days  of  arrival  in  port. 

Passengers  and  crews  of  suspected  ships  are  subject  to  surveillance 
for  more  than  five  days  after  arrival  of  the  ship  in  port. 

Soiled  linen  and  personal  effects  are  disinfected  and  such  parts  of 
the  ship  as  have  been  occupied  by  persons  infected  are  also  disinfected. 
For  plague,  all  rats  are  destroyed  and  for  cholera  the  bilge  water  is 
removed  and  good  drinking  water  substituted  for  that  on  board. 

(3)  Healthy  when  there  has  been  no  case  on  board  of  plague  or 
cholera  either  before  or  during  the  voyage,  nor  on  arrival  in  port. 

The  passengers  and  crews  of  healthy  ships  from  an  infected  port 
are  subjected  to  five  davs'  surveillance  after  departure  of  the  ship  from 
the  infected  port.  The  authorities  may  require  the  disinfection  of 
clothes,  the  destruction  of  rats  or  the  complete  emptying  of  the  bilge 
nyater. 


598  TROPICAL  HYGIENE,   SANITATION,   ETC. 

In  tropical  countries  it  is  more  difficult  and  costly  to  carrv  out 
these  measures  althoug'h  the  dangers  are  greater. 

At  ports  where  large  numbers  of  coolies  or  immigrants  are  arriving, 
there  is  usually  a  strict  quarantine  for  fourteen  days  at  a  quarantine 
station. 

This  is  followed  by  the  disinfection  of  the  clothes  and  the  bathing 
of  the  bodies  of  natives. 

For  English  Regulations  in  detail  see  the  Local  Government  Board 
Order  of  September  9th,    1907. 

IMMUNITY,  VACCINES  AND  SERA. 

SOME  PROPHYLACTIC  MEASURES  FOR  COMMON  INFECTIVE 

DISEASES. 

.  Vaccines  and  sera  are  administered  in  order  to  produce  partial  or 
complete  immunity  against  given  diseases. 

The  fundamental  principle  of  vaccine  therapy  is  "to  exploit  in  the 
interest  of  the  infected  tissues  the  unexercised  immunizing  capacities 
of  the  uninfected  tissues  "  (Wright). 

Immunity  depends  upon  some  property  in  the  living  blood  serum 
which  opposes  or  annuls,  in  part  or  wholly,  the  products  and  action  of 
the  infecting  organisms  (Whitelegge  and  Newman). 

Natural  Immunity  denotes  natural  resistance  to  some  given  disease, 
e.g.,  white  rats  are  immune  to  anthrax;  the  lower  animals  are  immune 
to  cholera  and  typhus  fever;  man  is  immune  to  swine  fever. 

Acquired  Immunity  may  be  acquired  as  the  result  of  a  natural  attack 
of  a  disease,  e.g.,  smallpox,  or  it  may  be  after  an  artificial  attack  of 
the  disease,  e.g.,  inoculation. 

Active  Acquired  Immunity  is  produced  as  the  result  of  inoculating 
attenuated  bacteria  into  the  tissues,  e.g.,  as  for  rabies. 

Passive  Acquired  Immunity  is  produced  by  inoculation  of  anti- 
toxins into  the  tissues,  e.g.,  diphtheria. 

Vaccination  is  an  inoculation  by  an  attenuated  virus. 

Vaccines  are  prepared  from  laboratorv  bacteria  or  bacteria  from  the 
patients  about  to  be  treated.  These  latter  are  known  as  autogenous 
vaccines.  The  bacteria  are  isolated,  cultivated,  killed  by  heat  or  anti- 
septics, tested  for  sterility,  counted  and  preserved  in  antiseptics. 

Imported  vaccines  do  not  keep  at  all  well  in  the  tropics.  To  pre- 
serve them  for  the  longest  time  possible  cut  a  portion  of  banana  stem, 
clear  out  the  central  core,  insert  the  vaccines,  plug  up  the  ends  of  the 
banana  stem  with  a  piece  of  the  same  material  and  keep  in  a  cool 
place.  The  internal  temperature  of  a  banana  stem  is  23°  to  25°  C, 
and  is  fairlv  constant  for  some  davs.  When  becominsf  drv  make 
another.  The  interior  can  be  cooled  dailv  by  sprinkling  it  and  its 
contents  with  ethvl  chloride. 


IMMUNITY,    J'ACCINES   AND   SERA  599 

Some  medical  officers  use  a  tube  of  asbestos  cloth  surrounded  by 
coKon  silicate,  the  whole  placed  within  a  wooden  or  bamboo  lube. 
Others  have  found  thermos  flasks  useful. 

TABLii;  OF  Vaccines  and  their   Doses. 

Vaccine  Appt'oxijiia/e  Dose 

Acne  bacillus  5  million  initial,  to  20  million 

Acne  bacillus  with  staphylococcus  5  million  with  100  million  increased 

IJacilius  septus  50-500  million 

Cerebro-spinal  meningitis  5-10  million  initial 

Cholera  No.  i  followed  by  No    2 

Coli  bacil'us  10-25  initial  up  to  500  million 

Diphtlieria  10-100  million 

Friedliindei's  bacillus  50  million  initial  to  1,000  million 

Gonococcus  25-50  million  to  1,000  million 

Micrococcus  melitensis  25-250  million 

Pneumococcus  25-500  initial  to  500  million 

Staphylococcus  100-5,000  million 

Streptococcus  Up  to  500  million 

Typhoid  500-1,000  million.     (Broth  cultures) 

Dysenteiy  In  four  strengths,  for  immunizing  and 

curative  in  chronic  conditions 

Mallein  f  10-15  minims  in  humans 

1  I  c.c.  for  diagnosis  in  animals 

Plague  75-80  million  or  i  c.c. 

Vaccines  are  : — 

(i)  Killed  or  attenuated  org^anisms  with  or  without  toxins.  Such 
are  known  as  Bacterial  Emulsions. 

(2)  The  toxins  only  as  in   Mallein. 

(3)  The  fluids  of  animals  suffering  from  an  infectious  disease,  e.g., 
calf  lymph. 

(4)  Sensitized  vaccines. 

Antitoxic  Sera  are  usually  obtained  from  the  horse.  A  healthy  one 
is  reared,  tested  for  tuberculosis  and  glanders,  inoculated  with  atten- 
uated serum,  later  with  increasing  doses  of  virulent  toxin  until  a  higii 
degree  of  tolerance  has  been  obtained.  The  horse  rests  a  few  days,  16 
to  20  pints  of  blood  are  then  drawn  ofif  from  the  jugular  vein  into  sterile 
flasks,  the  serum  is  decanted  after  coagulation  and  mixed  with  anti- 
septic, it  is  tested  for  sterility  and  toxicity  and  then  standardized.  A 
standard  dose  is  sufficient  to  neutralize  a  given  minimal  lethal  dose 
in  an  animal  of  known  weight. 

A  unit  dose  of  antitoxin  will  exactly  neutralize  100  minimal  lethal 
doses.  In  diphtheria  a  unit  dose  of  loxin  will  kill  a  250  grm.  guinea- 
pig  in  four  days;  this  is  considered  as  a  minimum  lethal  dose.  The 
former  or  unit  dose  of  antitoxin  will  neutralize  the  latter  or  animal 
lethal  dose  and  prevent  symptoms. 

Sera  have  been  used  for  diphtheria,  tetanus  and  bacterial  dvsentery> 
with   high  value,   and   in  snake  bite  and  plague  with  some  value,   iXx. 
cholera  with  little  value,  and  in  tuberculosis  and  leprosy  with  doubtful 
value. 
18 


6oo  TROPICAL   HYGIENE,   SANITATION,   ETC. 

The  Protection  afforded  by  these  sera  and  vaccines  is  accounted  for 
along  the  lines  of  live  principal  hypotheses  as  follows  :  — 

(i)   The  Exhaiislion  (Pabulum)  Theory. 

During  the  first  attack  the  invading  organisms  remove  certain 
chemical  substances  necessary  for  their  own  growth  and  in  consequence 
the  same  species  cannot  later  reinvade  the  tissues  with  success  owing 
to  shortage  of  essential  chemical  food.     This  view  is  not  widely  held. 

If  correct,  each  specific  disease  must  have  a  specific  chemical 
pabulum  as  one  disease  is  only  protective  against  itself. 

(2)  The  Antidote  or  Retention  Theory. 

It  is  assumed  that  after  a  bacterial  atack  some  product  is  left  behind 
which  inhibits  any  further  multiplication  of  the  organism.  This 
theory  preceded  the  antitoxin  and  antibacterial  theories.  There  is 
experimental  evidence  in  support  of  it.  Some  of  the  bodies  being 
formed  are  known  as  Agglutinins,  which  agglutinate  bacteria  or 
corpuscles,  Cytolysins  which  destroy  living  cells  and  Precipitins  which 
precipitate  the  albumin  of  the  serum. 

They  have  been  summed  up  as  follows  :  — 

Antibody  Antigen  Action 

Antitoxin  Toxin  Neutralization 

Precipitin  Coagulable  protein  Precipitation 

Agglutinin  Cells,  bacteria,  &c.  Clumping 

Cytolysin,  including  bacte-  Cells,  bacteria,  &c.  Prepares  cells,  bacteria,  &c., 

riolysin  and  haeniolysin  for  solution  by  complement 

Opsonin  Cells,  bacteria,  &c.  Prepares  cells,  bacteria,  &c., 

for  ingestion  by  leucocytes 

Some  authorities  stale  that  opsonin  should  not  be  classed  as  an 
antibody.     Possibly  all  antibodies  may  play  the  part  of  an  opsonin. 

(3)  The  Acclimatisation  Theory. 

This  is  a  condition  of  increased  cellular  resistance  following  a 
bacterial  attack.  The  cells  acquire  a  tolerance  of  the  poison  so  that 
ordinary  symptoms  do  not  manifest  themselves. 

(4)  The  Phagocytic  Theory. 

The  phagocytic  cells,  polymorphonuclear  leucocytes,  mono- 
nuclears, &c.,  absorb  and  destroy  the  invading  bacteria.  The 
inoculation  of  an  attenuated  virus  is  said  to  stimulate  the  cellular 
activity  in  this  direction.  Metchnikoff's  views  were  based  on  this 
theory. 

Opsonin  (opsono  =  I  cater  for)  is  a  chemical  substance  in  the  blood 
stimulating  the  leucocytes  to  ingest  bacteria.  The  extent  of  its  action, 
known  as  the  opsonic  index,  is  a  valuable  test  in  estimating  the  trend 
of  immunization.     This  opsonic  index  is  estimated  by  comparing  th? 

number  of  bacteria   ingested  by  a  given    number   of   leucocytes   in  a 

normal  serum  and  in  a  "  stimulated  "  serum. 


IMMrXITV.    J'ACCINES   AND   SERA  6oi 

(5)  Ehrlich's  Side-chain    Theory. 

Antitoxins  and  antimicrobic  substances  are  assumed  to  be  normally 
present  in  the  blood,  which  when  stimulated  by  the  introduction  of  toxin 
become  increased.  A  central  or  mother  cell  is  imagined  which  throws 
off  two  varieties  of  small  cells.  These  are  receptor  cells  capable  of  com- 
bining with  food-stuffs  for  the  nourishment  of  the  mother  cell.  One 
variety  links  up  with  simple  food  substances,  the  other  breaks  down 
compound  bodies  preparatory  for  assimilation.  Toxins  also  have  two 
varieties  known  as  haptophores  and  toxophores.  One  becomes  fixed 
to  one  variety  of  the  receptor  cells  and  the  other  remaining  free,  and 
if  in  sufBcient  numbers,  produces  toxic  changes. 

If  the  dose  of  toxin  injected  is  small  the  mother  cells  throws  off  the 
receptor  cell  \\ith  the  toxin  attached,  such  passing  free,  and  now  being 
without  harmful  effect  because  it  is  ''  locked  up  "  by  the  attached 
receptor.  The  mother  cell  produces  more  receptors  so  as  to  exhaust 
the  toxins  if  these  latter  are  not  too  excessive.  The  mother  cell  then 
continues  to  throw  off  receptor  cells  into  the  circulation  unfixed,  seek- 
ing toxin  cells  to  fix,  but  if  these  latter  are  exhausted  the  excess  of 
receptor  cells  constitutes  antitc^xin  molecules  which  are  ready  to  render 
innocuous  or  non-toxic  an\'  new  toxic  substances  of  that  specific  nature 
which  may  enter  the  system.  Hence  immunity  is  established,  partially 
or  completely,  for  that  specific  disease.  The  toxins  may  be  of  the 
nature  of  albumoses,  and  the  a.ntiloxins  are  probably  of  the  nature  of 
globulins. 

The  immunity  afforded  may  be  feeble  and  of  short  duration — 
weeks,  months,  or  vears.     In  small-pox  seven  years  or  thereabouts. 

After  an  inoculation  there  is  an  increased  susceptibility  for  several 
days,  a  condition  known  as  anaphylaxis  or  a  negative  phase,  conse- 
quently just  after  an  inoculation  there  is  increased  susceptibility 
towards  the  disease.  Because  of  this  negative  stage  inoculations 
should  not  be  given  within  seven  to  ten  days  of  the  former  one. 

Inoculations  should  be  given  before  the  disease  is  established, 
during  the  prodromal  period  if  it  is  known,  or  antisera  may  be  given 
therapeutically  during  the  disease. 

As  to  plague  vaccine,  Ilaffkine  claims  that  the  case  mortality  is 
reduced  to  less  than  one-half  after  inoculation. 

Cholera  vaccine  gives  a  marked  protection  against  an  attack,  but 
the  case  mortality  amongst  the  inoculated  is  not  much  diminished. 

Antityphoid  vaccine  reduces  the  case  incidence  and  case  mortality 
as  confirmed  in  the  Great  European  War.  It  was  only  on  its  trial 
during  the  South  African  War.  The  protection  is  not  permanent  and 
lasts  but  from  six  to  twelve  months.  One  could  not  expect  an 
inoculation  to  be  permanent,  really  knowing  that  all  the  body  cells  are 
renewed  entirely  every  seven  years  or  so. 


6o2  TROPICAL  HYGIEXE,   SANITATION.   ETC. 

Bacterial  dysentery  vaccines  for  chronic  cases  are  most  useful  where 
there  are  epidemics  of  chronic  dysenter}^.  The  sera  are  more  useful  in 
the  acute  stage. 

Combined  vaccines  are  used  and  recommended  by  Castellani. 
One  vaccine  made  and  used  by  him  was  for  Cholera,  Plague,  Typhoid. 
Paratyphoid  A  and  B  and  I'ndulant  Fever  together.  The  inoculation 
was  harmless.  Time  and  experiments  alone  will  indicate  their  thera- 
peutic and  prophylactic  value. 


SECTION   IX. 
LABORATORY  HINTS. 

THE    EXAMINATION     OF    THE    BLOOD.    INCLUDING:  — 

The  Preparation  of  Slides. 
The  Choice  of  Stains. 
The  Fixing  of  Films. 
.A.  Differential  Leucocyte  Count. 
Abnormal  Blood-cells. 

The  Estimation  of  Red  Blood-cells  and  ILemogloein. 
To  Demonstrate  Living  Malarial  Parasites. 
To  Stain  Malarial  Parasites.     Their  Varieties. 
To  Demonstrate  Micro-filari.^2. 
The  W'assermann  and  Widal  Reactions. 

To  Estimate  the  Specific  Gravity  of  the  Blood,  Spectroscopic  Examina- 
tion, and  the  Tonicity  of  the  Blood. 
Spectroscopical  Examination. 
The  Tonicity  of  the  Blood. 

TFIE    EXAMINATION     OF    MICRO-ORGANISMS  :  — 

Staining  Methods. 

Diagnostic  Features  of  Micro-organisms. 

The  Preparation  of  Cultures  and  Culture  Medla. 

THE    PREPARATION    AND    STAINING    OF    SECTIONS. 

MALARIAL    PIGMENT,    WHERE    IT    IS    AND    HOW    TO    FIND    IT. 

THE    TRICHOMYCETES. 

THE    HYPHOMYCETES    (MOULDS). 

THE    BLASTOMYCETES    (YEASTS). 

THE    EXAMINATION    OF    F.ECES. 

Macroscopical^  Microscopical,  including  Ova. 
Diagnostic  Features  of  Ova. 

THE    DISSECTION    OF    MOSQUITOES. 
THE    EXAMINATION    OF    WATER. 

Biological,  Bacterial,  Physical,  Chemical. 

THE    EXAMINATION    OF    SEWAGE. 
THE    ANALYSIS    OF    MILK. 


6o4  LABORATORY  HINTS 


LABORATORY    HINTS. 

THE  EXAMINATION  OF  THE   BLOOD. 

To  Clean  Slides. 

Slides   should   be   of   the    medium,    not    the    best,    quality    for    the 
tropics. 

Boil  in  strong  soda  Avater  for  five  minutes. 
Wash  well  in  running  water. 
Place  in  50  per  cent.  ILSOj  fur  ti\e  minutes. 
Wash  thoroughly  to  remove  all  acid. 
Drain  and  place  in  methylated  spirit. 

To  Clean  Cover  Slips. 

These  should  be  of  the  best  quality. 

Boil  for  ten  minutes  in  bichromate  soluiion  with  a  low  flame. 

Wash  well  and  remove  all  traces  of  yellow  colour. 

Drain  and  place  in  methylated  spirit. 

CHOICE  OF  STAINS. 

Basic  stains  do  well  for  newly  growing  cells,  but  more  mature  and 
permanent  ones  as  red  cells  take  acid  stains  better. 

Hematoxylin  and  eosin  are  good  in  the  tropics  and  do  not  fade. 

Leishman's  stain  is  better  at  first  but  fades  later. 

Hematoxylin  should  be  matured  in  (|ua1ily  by  light  and  air. 

Leave  the  bottle  in  the  sun  with  the  cork  loose. 

To  stain    for  blood   changes,    use   hematoxylin   and   eosin,    but  use 
Leishman's  for  unfixed  blood  films. 

To    stain    for    bacteria,    use    Loefifler's    methylene    blue    or    carbol 
fuchsin  (dilute,  four  minutes). 

To  stain  for  animal  and  vegetable  parasites,   use  carbol   thionin  or 
carbol   fuchsin. 

Another  film  must  be  used  for  the  acid-fast  test. 

To  stain  for  tissue  changes  in  sections,  use  hematoxylin  two  and 
a  half  minutes,  eosin  ten  .seconds. 

If  for  protozoal  parasites  use  :  — 

Hematoxylin,  fifteen  minutes,  acid  alcohol  ten  seconds,  or 
Carbol  thionin  or 
\^an  Gieson  stain. 


TIJE  EXAMINATION   OF  THE   HLOOD  605 

TO  FIX  BLOOD  FILMS. 

Agents. — Time,  lieat,  Ilg-  perchloride,  formalin,  csmic  acid, 
absolute  alcohol. 

The  best  is  absolute  alcohol  and  ether,  equal  parts. 

Place  blood  films  in  it  from  ten  minutes  to  ad  lib. 

This  solution  does  not  lose  its  fixative  power. 

Blood  films  to  be  stained  with  Leishman's  need  no  fixing  at  all. 

A  NORMAL  DIFFERENTIAL   BLOOD   COUNT   WILL   SHOW  :— 

Some  ''  blood  dust  "  which  must  not  be  taken  for  parasites,  though 
Brownian  movement  may  be  present. 

Leucocytes. — 6,000-8,000  per  c.mm. 

Lymphocytes. — 15-25  per  cent.  They  have  a  large  deep  staining 
nucleus  with  little  protoplasm. 

Large  Mononuclears. — 5-10  per  cent.  These  are  larger  cells  with 
a  larger  and  paler  nucleus  with  more  protoplasm. 

Polymorphonuclears. — 65-75  P^*'  cent.  There  are  several  nuclei 
which  are  connected  by  nuclear  filaments. 

Eosinophiles. — 1-3  per  cent.  The  granules  show  an  affinity  for 
acid  stains. 

Transitional. — Few.     These  have  a  horseshoe-shaped  nucleus. 

Remember  that: — 

(i)  The  lymphocytes  are  increased  during  digestion,  scurvy  (60  per 
cent,  are  Ivmphocvtes),  lymphatic  leukaemia  (70-85  per  cent,  are 
lymphocytes),  enteric  and  Malta  fever,  but  these  latter  are  not  constant. 

(2)  The  large  mononuclears  are  increased  during  malarial  fever 
(15-20  per  cent.).  This  is  not  reduced  after  taking  quinine.  Quinine 
may  have  cleared  up  the  parasites,  but  the  above  condition  will  assist 
the  diagnosis. 

(3)  The  polymorphonuclears  are  increased  physiologically  during 
youth  and  pregnancv,  and  pathologically  during  suppuration  and 
pneumonia. 

(4)  Eosinophiles  are  increased  during  worm  infections,  e.g., 
trichiasis,  bilharziasis,  filariasis,  &c.  Trypanosomiasis,  verminous 
conditions,  asthma  and  bronchitis,  urticaria,  pemphigus,  and  after 
dietetic  errors,  such  as  "  high  "  cheese,  venison,  &c. 

(5)  The  total  leucoc\'tes  are  diminished  in  trypanosomiasis  and 
knia-azar  (,^,000  or  less). 

ABNORMAL  BLOOD  CELLS. 

White  Cells. 

Mast  cells  are  degenerated  leucocytes  of  the  polynuclear  type. 

The  nucleus  stains  poorly.  The  granules  are  coarse  and  are  called 
meta-chromatic  granules,  because  they  neither  take  h^ematoxylin  nor 
eosin  well,  but  stain  better  with  a  combination  of  the  two. 


6o6  LABORATORY    HINTS 

Leishman's  is  good  and  gives  them  a  brownish  lint.  They  are 
sometimes  found  in   normal  blood.     Their  significance  is  not  known. 

In  lymphatic  leukc\?mia  the  leucocytes  are  irregular  in  size,  shape 
and  staining  qualities.     Tlie}-  are  increased  to  14,000  per  c.mm. 

From  70  to  98  per  cent,  are  lymphocytes.  The  red  cells  are 
diminished  in  number  and  hb. 

In  spleno-medullary  leukcemia,  myelocytes  are  found.  The  cell 
may  be  very  large  or  smaller  than  normal,  the  nucleus  stains  poorly, 
and  it  is  sometimes  studded  (U'er  with  eosinophilic  granules.  These 
cells  are  pathognomonic  of  this  disease.  As  a  rule  they  are  more 
numerous  and  larger  than  any  other  leucocyte.  The  nucleus  is 
never  horseshoe-shaped.  The  blood  looks  milkv.  The  red  cells  are 
reduced  to  700,000  per  c.mm.,  some  are  nucleated.  There  are  also 
polychromatic  and  mast  cells. 

Red  Cells. 

Variation  in  colour  usually  indicates  the  amount  of  hb.  A  rough 
indication  of  anasmia  is  thus  given, 

Poikiloc^^tosis  as  seen  in  pernicious  auccmia  ma}'  be  imitated 
artificially  in  making  the  film  by  drawing  the  cells  down  one  slide 
with  another,  but  the  elongation  is  in  the  same  direction  in  all  the 
cells.  To  avoid  it  in  making  a  blood  film  \\\\h  two  slides,  the  drop 
of  blood  should  be  drawn  away  from  the  operator  and  not  pushed  awav 
with  the  second  slide. 

Nucleated  red  cells  may  appear  in  normal  blood,  ]3rimar\-  and 
secondary  ana?mia.  The  nucleus  may  be  divided,  or  it  may  appear 
as  two  rounded  bodies. 

Polychromatic  cells  are  not  uncommon  in  the  ana?mias,  especiallv 
in  malaria.  They  are  degenerated  red  cells  and  take  up  both  eosin 
and  methylene  blue. 

Some  red  cells  are  basophilic;  thev  show  slippled  dots  peripherally 
which  may  be  polychromatic.  Thev  indicate  a  degenerative  process. 
They  are  very  common  in  lead  poisoning.  They  do  not  indicate 
latent  malaria  as  Plehn  supposed. 

COUNTING    BLOOD    CELLS    AND    ESTIMATING    HB. 
To  Count  Red  Cells. 

Use  Gowers's  hfemacytometer. 

Draw  into  the  pipette  blood  from  a  small  needle  wound  in  the  lobe 
of  the  ear  or  finger-lip  up  lo  the  mark  on  the  stem  near  the  bulb. 

Fill  to  mark  above  the  bulb  with  Hayem's  solution. 

Shake  well,  then  place  one  drop  on  special  slide  provided. 

Place  on  this  a  cover  slip.  The  drop  should  cover  the  central  disc, 
but  should  not  run  over  this  so  as  to  come  between  the  cover  slip  and 


THE  EXAMINATION  OF  THE  BLOOD  607 

the  main  slide.  Practice  will  soon  enable  one  to  estimate  the  size  of 
drop  required. 

Use  i-in.  lens  and  Xo.  4  eye-piece  and  focus  so  that  a  set  of  sixteen 
squares  is  seen. 

Count  the  red  cells  in  each  square  and  on  two  sides  of  it. 

Count  up  four  sets  or  more  of  sixteen  scjuares  each  and  divide  the 
stun  bv  the  number  in  each. 

Thus  sixty-four  squares  contain  768  red  cells  =  12  in  each  scjuare. 
The  content  of  each  square  is  4o  x  2^5  x  t\t  =  40V0    c.mm. 

Hence  one  c.mm.  of  the  solution  contains    473750    ^    12  red  cells. 

lUit  the  solution  was  diluted  100  times  with  the  sodium  sulphate 
solution. 

Hence  i   c.mm.  of  blood  contains       '""        =  4,800,000  red  blood 

,,  4COO    X     12 

cells. 

For  White  Cells. 

l\se  I  per  cent,  acetic  solution  and  a  drop  of  methj-lene  blue.  A 
separate  pipette  giving  a  10  per  cent,  dilution  is  better. 

In  estimating  the  Hb.  in  the  Tropics. 

A  book  \\ith  stained  papers  and  corresponding  blank  blotting 
papers  is  used. 

A  little  of  the  latter  is  touched  with  the  blood,  and  then  is  matched 
with  the  stained  paper,  which  gives  the  percentage  of  hb. 

A  small  book  costing  5s.  will  last  five  vears. 

TO  DEMONSTRATE   LIVING   MALARIAL   PARASITES. 

Take  a  small  drop  of  blood  on  centre  of  cover  slip. 

Edge  the  cover  slip  with  vaseline  and  place  it  on  a  slide. 

Examine  middle  zone  with  a  T^-'n-  objective. 

In  the  outer  zone  are  rouleaux. 

In  the  middle  zone  are  single  red  cells. 

In  the  central  zone  very  few  red  cells. 

A  dull  light  is  required  as  corpuscles  are  colourless. 

The  parasite  will  be  seen  in  a  red  cell  and  pigment  in  the  parasite. 

If  the  field  is  flooded  with  light  the  pigment  is  still  clearly  seen, 
but  the  granular  leucocyte  is  not  clearly  seen. 

The  parasite  shows  amoeboid  movement  ;  the  males  will  throw  out 
long  pseudopodia  which  lash  the  red  cells,  and  eventually  become  free 
to  enter  the  female  cell.     The  actual  entry  has  not  been  witnessed. 

TO  STAIN  THE  MALARIAL  PARASITE  IN  THE  BLOOD. 

(i)  Leishman's  stain  is  the  best.     It  is  polychrome.     No  fixing  is 
recjuired. 
The  eosin  stains  the  red  cells. 


6o8  LABORATORY    HINTS 

The  red  methylene  blue  stains  the  chromatin. 

The  blue  methylene  blue  stains  the  nucleus. 

The  soloids  are  dissolved   in   pure   metliyl-alcohol   and   put   up 

in  phials. 
The  film  should  be  fresh  and  imfixed. 
Stain  half  to  one  minute. 
Add  distilled  water  in  drops  as  2  to   i  of  stain  and  move  about 

gentlv  five  to  seven  minutes.     One  can  see  under  l^  in.  when 

it  is  stained  sufiliciently. 
Flush  ofif  with  distilled  water. 

Dry  and  mount  with  Canada  balsam  and  cover  slip. 
Unmounted  blood  films  will  keep  a  long  time. 
Other  methods  are  :  — 

(2)  Borax  meth^dene  blue. 

Fix  in  alcohol  and  ether,  ten  minutes. 

Dry  and  stain  with  borax  methylene  blue,  thirty  seconds. 

Wash  well,  dry  and  mount. 

This  will   not  differentiate  the  chromatin. 

It  is  not  so  good  for  the  white  cells. 

It  is  better  than  Leishman's  for  old  films. 

(3)  Haematoxylin  and  eosin. 

Fix  in  alcohol  and  ether,  ten  minutes  or  more,  and  dry. 
Stain  with  haematoxylin,  seven  minutes. 
Flush  off  with  tap  water  for  five  minutes. 
vStain  with  eosin,   thirty  seconds. 
Wash,  dry  in  air,  mount. 

(4)  Carbol-thionin. 

Fix  in  alcohol  and  ether,  ten  minutes. 

Dry  and  stain  with  dilute  carbol  thionin,  ten  minutes. 

Wash,  dry  and  mount. 

Strong  solutions  are  used  for  sections.     This  will  keep. 

This     is     diluted     with     three     parts    of     water     for    blood 
films. 

This  soon  degenerates — twent}'-four  hours. 

One  cannot  over-stain  with  it. 

The  older  the  film  the  less  time  required  for  staining. 

(5)  Eosin-azur.     No  fixing  required. 
This  stain  shows  up  the  crescents  well. 

Stain   as  with   Leishman's;   onlv    use   three   times   the   distilled 

water  from  twelve  to  fifteen  minutes. 
Dissolve  one  soloid  in  10  c.c.  of  methyl  alcohol. 
It  is  tw^ice  the  price  of  Leishmnn's  stain. 
This  is  good  for  the  trvpanosome  and  halteridium. 


THE  EX.IMIXATION   OF  THE  BLOOD  609 

THE  VARIETIES  OF  MALARIAL  PARASITES. 

There  are  three  to  look  for  :  — 

The  benig^n  tertian  parasite  full\'  i^r.nxn   in  fort\-eight  hours. 
The    subtertian,    t-estivo-autumnal    or    malignant    parasite,    fully- 
grown  in  tliirty-four  to  forty-eight  hours. 
The  quartan  parasite  full^'  grown  in  seventy-two  hours. 

There  may  be  several  "  crops  "  of  one  parasite,  so  that  the  same 
slide  may  show  two  or  three  groups  at  different  ages. 

There  may  be  a  multiple  infection,  two  varieties  of  parasites  in  the 
same  film. 

One  family  of  parasites  may  be  so  few  in  number  that  there  will 
be  no  corresponding  rise  of  temperature. 

If  there  are  two  infections  of  the  same  varietv  the  rises  of  tempera- 
ture are  seldom  equal. 

In  benign  tertian  the  red  corpuscle  is  enlarged  and  pale. 
Schiiffner's  dots  ma\'  be  seen,  which,  consist  of  peculiar  granular 
degeneration  staining  brick  red  and  diagnostic  of  benign  tertian. 
Parasites  are  plentiful  in  the  peripheral  blood,  but  tend  to  sporulate 
in  the  deeper  organs;  the  gametocvte  is  rounded  or  ring-shaped,  fifteen 
to  twenty-five  spores,  yellow  brown,  pigment  coarse.  Active  amoeboid 
movement.     Life-cycle   forty-eight   hours. 

In  the  subtertian  the  red  cell  is  smaller,  no  St-liiiffner's  dots. 
Young  ring  forms  are  seen  in  the  peripheral  blood,  but  not  always; 
it  matures  in  the  deeper  organs.  The  sporulating  form  found  in  the 
spleen  ma}'  be  seen  in  the  peripheral  blood  just  before  death.  The 
corpuscle  becomes  yellow — "  brassv  bodA-."  The  gametocyte  is 
crescentic  in  shape,  pigment  black  and  fine.  It  is  very  amoeboid. 
Life-cycle  is  variable,  perhaps  thirty-four  to  forty-eight  hours. 

Spores,  7-8,  rarely  20.     Very  active,  but  small  processes. 

The  male  and  female  cells  can  be  distinguished. 

Male,  has  pigment  and  chromatin  more  scattered. 

Female,  one  central  mass  of  chromatin  with  the  granules  arranged 
around  it.  There  ma}-  be  two  or  three  or  more  small,  clean-cut  ring 
forms  in  'one  cell  which  is  rare  in  benign  tertian  or  quartan. 

Some  subtertian  parasites  mav  be  seen  that  have  not  penetrated 
the  red  cell  which  is  uncommon   in  benign  tertian. 

The  chromatin  is  more  flattened,  and  not  knob-shaped  as  in  benign 
tertian. 

A  second  slide  taken  twenty-four  hours  later  \\-\\\  show  parasites 
enlarged  if  benign,  but  the\-  will  be  little  altered  or  gone  to  the  deeper 
organs  to  sporulate  if  subtertian. 

In  benign  tertian  and  quartan  there  are  usuallv  a  few  earlv  or  late 
sporulating  parasites  which  would  not  be  seen  in  subtertian. 


6io  LABORATORY    HINTS 

The  finding  of  crescents  establishes  the  diagnosis. 

A  sporulating  subtertian  fills  about  one-third  of  the  red  cell. 

A  sporulating  quartan  fills  the  cell. 

The  crescents  or  subterlian  gametoc^^tes  are  especially  interesting. 

The  sexes  are  differentiated.  They  do  not  produce  fever,  'i'hey 
undergo  no  change  in  man's  blood.  The}^  appear  one  week  after  the 
fever  has  commenced  and  persist  for  six  \\eeks  after  quinine  has  been 
given.  Although  the  patient  has  no  fever,  he  is  infective  as  long  as 
these  crescents  remain  in  the  blood. 

In  the  quartan  parasites  the  red  cells  are  never  enlarged.  The 
affected  cell  is  darker  than  the  normal  ones,  it  requires  longer  to 
develop,  seventy-two  hours;  it  has  fewer  spores,  five  to  twelve,  than 
benign  tertian,  but  they  are  the  largest  of  all.  Sporulates  in  the  peri- 
pheral blood.  Corpuscle  becomes  smaller  and  darker.  Gamete 
rounded,  the  pigment  is  black,  and  granules  coarse.  There  is  little 
amoeboid  movement.  The  parasite  may  be  stretched  out  across  the 
cell  "cigar-shaped,"  when   it  is  called  an  "equatorial  "  parasite;. 

The  pigment  of  the  male  dances  about,  throws  off  flagella  which 
are  very  active.  In  ten  to  fifteen  minutes  they  break  off  and  swim 
freely  in  the  blood  until  they  pierce  a  female  cell.  The  female  cell  is 
quiescent  after  the  polar  bodies  have  been  extruded.  The  fertilized 
female  or  zygote  becomes  oval  "  ookinet,"  and  later  when  it  moves 
it  is  known  as  a  travelling  vermicule.  The  leucocvtes  gather  around 
the  male  cell  when  the  flagella  have  been  thrown  off  and  remove  them. 
This  process  can  be  seen  under  the  microscope  in  specimens  of  fresh 
blood. 

TO  EXAMINE  FRESH  BLOOD  FOR  MICROFILARIAE. 

Make  a  thick  film  of  several  drops  of  blood  and  let  it  dry. 
Place   it   inverted   in   a  watch-glass  of  water  so  as  to   remove   hb. 
from  the  blood. 

Fix  it  in  alcohol  and  ether. 

Stain  ^\•ith  hot  hc'ematoxylin  five  minutes,  then  flush  with  water. 

Examine  while  wet.     Repeat  stain   if  not  well  blue. 

Dry  and  mount. 

THE   WASSERMANN   REACTION    (FLEMING'S   MODIFICATION). 

This  important  diagnostic  reaction  of  the  blood  depends  upon  the 
l^rinciple  of  hiemolwsis.      If  the  case  for  diagnosis  be  really  a  case  of 
syphilis,    then    no    hasmolvsis    will    occur.     A    control    experiment    is 
carried  out  at  ihe  same  time,  using  normal  serum. 
The  substances  required  are: — - 

(i)  An  alcoholic  extract  of  heart  muscle.  It  is  made  from  i  grm. 
of  heart  muscle  (guinea-pig)  rubbed  in  a  mortar  with  25  c.c. 
absolute  alcohol,  heated  to  60°  C.  for  an  hour  and  filtered. 


THE  EXAM  I  SAT  ION   OF  THE   BLOOD  6ii 

(2)  Sheep's  corpuscles  washed  and  dihited  with   normal  sah'ne. 

(3)  vSerum  in  an  ordinary  blood  tube. 

Use  a  throttle  pipette  with  a  long-  stem  and  rubber  teat. 

Half  an  inch  from  the  capillarv  end  mark  with  a  grease  pencil. 

'J'his  equals  one  volume.     Permit  a  bubble  of  air  and  draw  up 

another  volume,   and  so  on   until  all   required  are  drawn   up 

into  the  pipette.     Prepare  the  following  :  — 

(i)  Extract  of  heart  muscle        ...         ...  4  volumes 

Syphilitic  serum          ...          ...          ...  i  ,, 

(2)  Heart  muscle 4  ,, 

Normal  serum             ...         ...         ...  i  ,, 

(3)  Normal  saline             ...         ...         ...  4  ,, 

Syphilitic  serum          ...         ...         ...  i  ,, 

(4)  Normal  saline             4  ,, 

Normal  serum             i  ,, 

(5)  Heart  muscle 4  ,, 

Incubate  all  these  for  one  hour  at  37*^  C.  Add  then  to  each  tube  one  volume  of 
sheep's  corpuscles.  Incubate  again  for  one-and-a-half  to  two  hours.  The  results  should 
now  be : — 

No  haemolysis  in  tubes  (i)  and  (5) 
Haemolysis  in  all  the  others. 

The  heart  contains  a  syphilitic  antigen  which  serves  the  same 
purpose  as  a  syphilitic  foetal  liver.  To  discuss  the  whole  biochemical 
process  is  not  our  purpose,  but  the  explanation  of  the  reactions  in  each 
tube  is  here  given  in  brief. 

(i)  Syphilitic    antigen    in    extract     +     syphilitic    serum    (svphilitic 
amboceptor    +    complement)    +   sheep's  corpuscles. 
The  complement  is  fixed,  therefore  there  is  no  hcemolysis. 

(2)  Syphilitic   antigen     +    normal    serum    (non-specific   amboceptor 

+   complement)   +   sheep's  corpuscles. 
The  complement  is  not  fixed,  therefore  hcemolysis. 

(3)  Xormal    saline     +     syphilitic    serum    (amboceptor     +     comple- 

ment)  +   sheep's  corpuscles. 
The  complement  is  not  fixed,  therefore  haemolysis. 

(4)  Normal   saline    +    normal   serum   (amboceptor    +    complement) 

+   sheep's  corpuscles. 

The  complement  is  not  fixed,  therefore  ha?moIvsis. 

(5)  Antigen  +  sheep's  corpuscles  (no  amboceptor,  no  complement). 
Therefore  there  is  no  haemolysis. 

THE  WIDAL  REACTION. 

An    important    diagnostic    blood    reaction    for    tvphoid    and    allied 
fevers,  depending  upon  the  agglutination  of  the  bacteria. 
Clean  the  lobe  of  the  ear  with  ether. 

Collect  a  few  drops  of  blood  in  a  sterile  capillary  tube. 
Seal  the  ends  in  a  flame  with  blood  in  tlie  central  part. 


6i2  LABORATORY   HINTS 

Centrifuge  or  let  it  stand  several  hours,  break  off  end,  and  blow  out 
serum  when  required. 

Use  a  pipette  as  for  the  Wassermann   reaction. 

Draw  seven  volumes  of  normal  saline  into  pipette. 

Express  one  volume  on  each  of  seven  clean  slides  or  one  large  slide. 

Take  one  volume  of  serum  to  be  tested  and  place  on  a  clean  slide. 

Take  another  volume  of  serum  to  be  tested  and  place  on  a  slide 
with  one  volume  of  saline. 

71iis  serum  is  now  diluted   i  in  2. 

Take  one  volume  of  this  latter,  mix  with  another  slide  with  one 
volume  of  saline. 

This  is  I   in  3  dilution. 

Repeat  this  process  through  the  series  excepting  the  seventh  slide, 
as  this  last  is  of  normal  saline  for  a  control. 

Take  a  thick  emulsion  of  typhoid  bacilli  from  an  agar  culture. 

Add  one  volume  of  this  to  each  of  the  slides  and  mix  well. 

Examine  under  a  i-in.  objective. 

The  reaction  is  positive  if  complete  agglutination  occurs  imme- 
diatelv  in  the  i  in  2  dilution  and  within  half  an  hour  in  the  i  in  6 
dilution. 

These  can  be  examined  by  drawing  them  up  into  a  long  pipette 
separated  bv  an  air  bubble,  or  separate  fluid  drops  on  one  large  slide 
or  on  separate  slides. 

THE  SPECIFIC  GRAVITY  OF  THE  BLOOD. 

From  1035  to  1068. 

To  estimate  it  prepare  a  fluid  of  glycerine  and  water  or  chloroform 
and  benzol  in  known  proportion  about  the  normal  specific  gravity  of 
the  blood. 

Place  in  it  one  drop  of  blood,  and  alter  the  specific  gravity  of  the 
.fluid  bv  adding  glycerine  and  water  or  chloroform  and  benzol  until 
the  drop  neither  floats  nor  sinks.  The  specific  gravity  of  the  fluid  is 
then  that  of  the  blood. 

THE   SPECTROSCOPIC   EXAMINATION. 

A  small  direct  vision  spectroscope  is  the  most  useful. 

Dilute  the  blood  with  distilled  \\aler. 

Focus  the  spectrum,  closing  the  slit  as  much  as  possible  so  as  to 
bring  out  Fraunhofer's  lines  distinctly. 

Oxy haemoglobin  and  reduced  haemoglobin  can  be  obtained  from 
the  same  specimen  by  shaking  it  up  with  air  to  oxidize  it  and  adding 
ammonium  sulphide  to  reduce  it. 

Oxyhiemogkjbin  shows  two  narrow  une([ual  dark  bands  between 
the  lines  D  and  E. 


THE   EXAMINATION    OF    MICRO-ORCANISMS  613 

Reduced  hcTmoglobin  shows  one  broad  band  between  lines  D 
and   E. 

Metha^moglobin  sliows  two  equal  bands  between  D  and  I{  and  one 
between  C  and  D.  The  urine  is  brown.  It  is  often  seen  in  mild  cases 
of  blackwater  fever. 

Urobilin  shows  one  broad  band  between  E  and  F. 

THE  TONICITY  OF  THE  BLOOD. 

Some  specimens  of  corpuscles  have  the  power  of  retaining  hb. 
better  than  others.  Distilled  water  will  remove  the  hb.  but  saline 
solution  over  a  certain  strength  will  not  remove  it.  The  resistance 
or  tonicitv  can  be  measured  by  the  strength  of  that  saline  solution 
which  is  just  sufiticient  to  prevent  the  solution  of  the  hb.  This 
solution  is  said  to  be  "  isotonic."     Normal  blood  is  hypertonic. 

Normal  saline  solution,  75  per  cent.,  prevents  the  solution  of  the  hb. 

Make  a  series  of  weaker  solutions  differing  o"02  per  cent. 

Place  one  drop  of  blood  in  this,  shake  and  allow  to  stand. 

The  weakest  saline  solution  that  does  not  cause  solution  of  the  hb. 
is  the  index  of  the  tonicity  of  the  blood  used.  The  normal  is  o"46  to 
0*48  per  cent. 

A  decrease  of  tonicity  often   precedes  a  h^emolytic  attack. 

Persons  of  a  normally  low  tonicity  should  not  be  allowed  to  live 
where  blackwater  fever  is  endemic. 

THE  ENAAIINATIOX  OF  ?^IICRO-ORGAXISAlS. 

TO  STAIN  MICRO-ORGANISMS. 

The  Gram  method  is  important. 

To  Stain  Smears. 

Stain  witli  aniline  gentian  violet,  five  minutes. 
Pour  off,  treat  with  Gram's  iodine  solution,  two  minutes. 
Pour  off,  treat  with  alcoholic  eosin  until  the  colour  ceases  to  come 
out  freely. 

Wash,  dry  and  mount. 

Gram's  iodine  is  i  part  of  potassium  iodine  and  300  parts  of  water. 

Jo  Stain  Sections. 

Stain  with  aniline  and  gentian  violet,  ten  minutes. 

Stain  with  Gram's  iodine,  two  minutes. 

Pour  off  and  blot. 

Stain   with  alcoholic  eosin,   thirty  seconds. 

Oil  of  cloves  and  xvlol. 


6i4 


LABORATORY   HINTS 


Important  Differentiations. 


Gram-positive 

G?-ain-jiei^a/ive 

Staphylococcus,  all  varieties 

Bacillus 

i  mallei 

Streptococcus  pyogenes 

n 

coli  communis 

Micrococcus  tetragenus 

)' 

coli  dysenteria? 

Fraenkel's  bacillus 

n 

enteritidis  (Gartner) 

Bacillus  acne 

>) 

pestis 

,,         anthracis 

)> 

pyocyaneus 

,,         botulinus 

)' 

influenza' 

„         diplitheri?e 

)) 

Friedlander's  pneumo 

„         enteritidis  (Klein) 

J» 

malignant  oedema 

„         Oppler-loas 

u 

prodigiosus 

,,         pseudo-diphtheriae 

> 

proteus  vulgaris 

„         xerosis 

■)1 

fluorescens 

,,         tuberculosis 

51 

smegmne 

„         smegtn?e  ? 

)t 

soft  sore 

„         leprs 

Di 

plococcus  intracellularis  meningitidis 

,,         subtilis 

D 

iplococcus  catarrhalis 

„         welch  ii 

Gonococcus 

,,         tetani 

Sp 

irillum  cholera  asiaticre 

Aspergillus 

Spiroch 

ietes  of  syphilis,  relapsing  fever. 

Sarcinas,  all  varieties 

Vincent's  angina,  and  other    para- 

Yeasts (blastoniycetes) 

sitic  protozoa 

Ringworm  fungi 

M 

icrococcus  melitensis 

Streptothrix  of  actinomycosis 

„                 madura  disease 

Most  organisms  when  stained  with  fuchsin  are  readily  decolorized 
by  weak  solutions  of  mineral  acids.  The  exceptions  are  :  Tubercle 
bacillus,  bacillus  leprcC,  smegma  bacillus,  the  bacillus  of  timothy 
grass,  the  dung  bacillus  and  others  less  important. 

If  an  organism  retains  its  stain  after  treatment  by  25  per  cent. 
H2SO4  or  30  per  cent,  nitric  it  is  acid-fast. 

The  Acid-Fast  Method. 

Stain  with  warm  carbol  fuchsin,  five  minutes.  (To  warm,  heat  a 
penny  over  a  Bunsen  flame  and  place  slide  upon  it.  Repeat  the 
process  during  five  minutes.) 

Decolorize  with  20  per  cent,  strong  HoSO,,  HXO3  or  HCl. 

Wash  well,  dry  and  mount  if  a  film;  dehydrate,  clear  and  mount  if 
a  section. 

Some  organisms  are  so  rapidly  decolorized  that  they  are  not  seen, 
as  the  pneumo-bacillus.  For  these  use  aniline  oil  instead  of  acid 
alcohol. 

Weigert's  Method. 

Aniline  gentian  violet,  five  minutes. 
Gram's  iodine,  two  minutes. 

Pour  off,  treat  with  aniline  oil,  then  stop  its  action  with  water. 
Counterstain  other  Grams  with    Bismarck   brown   one   minute,    or 
aqueous  eosin  20  seconds. 
Wash,  dry  and  mount. 


THE   EXAMINATION    OF   MICRO-ORGANISMS  615 

To  Find  the  Diplococcus  pneumoniae  stain  thus: — 

Aqua  eosin,  twenty  seconds. 

Wash,   treat  with  aniline  gentian  violet,   ten  minutes. 
Pour  off,  treat  with  Gram's  iodine,  two  minutes. 
Pour  off,  blot,  and  treat  with  aniline  oil  until  colour  ceases  to  come 
out  freely. 

Treat  with  xylol  to  stop  the  action  of  aniline  oil. 

To  Stain  Spores. 

Hot  carbol  fuchsin,  five  minutes. 

Wash,  treat  with  20  per  cent,  acid,  two  dashes. 

Wash  well  to  get  rid  of  the  acid. 

Stain  with  Loeffler's  blue,  four  to  five  minutes. 

Wash,  dry  and  mount. 

In  examining  a  micro-organism  ascertain  its  :  — 

Motility,  morphology,  acid-fast  or  not,  Gram-positive  or  not,  does 
ir  form  spores  or  not. 

Remember  that  no  acid-fast  organism  is  motile, 

no  coccus  is  acid-fast  or  forms  spores, 
all  acid-fast  organisms  are  Gram-positive, 
Gram-negative   organisms  are   non-sporing  except 
the  bacilli  of  malignant  oedema. 

Thus  a  cholera  vibrio  would  be  motile,  hence  it  would  not  be 
acid-fast  nor  would  it  form  spores. 

Motility  depends  upon  flagella  but  the  extent  of  movement  does 
not  depend  upon  the  number  of  flagella.  These  latter  are  difficult  to 
stain  and  readily  break  off. 

Brownian  movement  can  be  performed  by  inanimate  matter  as  well 
as  by  some  micro-organisms. 

TO  DIAGNOSE  MICRO-ORGANISMS. 

One  must  know  their  morphology. 

The  chief  ones  from  the  acid-fast  group  are  :  — 

(1)  The  Tubercle  Bacillus. 

A  non-motile  slender  rod  with  rounded  ends,  often  slightly  curved, 
2'5  to  5  /x  long.  Some  portions  do  not  stain  well  and  hence  it  often 
presents  a  "beaded  "  appearance. 

It  is  acid-fast. 

The  culture  is  aerobic  and  facultatively  anaerobic. 

Grows  slowly  at  blood  heat. 

In  glycerine  broth  it  develops  as  a  floating  pellicle. 

On  glycerine  agar  it  gives  a  creamish.  dry  and  wrinkled  film. 

It  does  not  liquefy  gelatin. 

39 


6i6  LABORATORY   HINTS 

Pure  cultures  can  be  formed  by  inoculating  a  guinea-pig  from 
tubercular  sputum. 

(2)  The  Bacillus  pseudo-tuberculosis  of  Pfeiffer. 

It  grows  rapid! V  and  readily  forms  a  creamy  growth  on  agar  very 
different  from  that  of  tubercle.  On  gelatin  a  whitish  growth  without 
liquefaction.  It  is  not  acid-fast.  Is  Gram-negative.  Found  in  milk 
and  sewage.     Pathogenic  to  guinea-pigs  and  rabbits. 

(3)  The  Bacillus  leprae. 

A  long  slender  straight  rod,  with  somewhat  pointed  extremities, 
non-motile,  does  not  form  spores.     Gram-positive.     Acid-fast. 

Stains  more  rapidly  and  decolorizes  more  readily  than  the  tubercle 
bacillus.     Attempts  to  grow  cultures  have   not  been   very  successful. 

(4)  The  Smegma  Bacillus. 

Shorter  and  flatter  than  the  tubercle  bacillus  in  cultures. 
Grows  readily,  acid-fast. 
Non-pathogenic  in  small  infections. 

(6)   The  Bacillus  of  Timothy  Grass. 

Acid-fast.     Resembles  tubercle  bacilli,  but  is  harmless. 
It  grows  readilv  in  any  ordinary  medium. 

It  is  found  in  fodder  about  cow-sheds,  and  when  in  milk  may  be 
taken  for  the  tubercle  bacillus. 

The  chief  ones  from  the  spore-forming  groups  are  :  — 

(1)  The  Anthrax  Bacillus. 

It  is  aerobic  and  facultatively  anaerobic.     5  to  6   /a    long. 

Non-motile,  scjuare  ends,  occurs  in  short  chains  and  singly  in  blood. 

Some  segmentation  may  be  seen  on  staining.  It  is  surrounded  by 
a  sheath  in  which  it  divides;  this  process  may  continue,  forming 
chains. 

In  the  presence  of  much  oxygen  and  a  temperature  of  20°  to  38° 
C.,  spores  are  developed,  but  only  after  death  when  the  blood  dis- 
charges come  into  contact  with  the  air.  In  cultures  it  liquefies  gelatin 
in  two  days. 

In  a  stab,  fine  branching  filaments  grow  outwards  from  the  needle 
track  called  the  "  inverted  fir  tree  growth."  Liquefication  begins  at 
the  top. 

In  both  a  focculent  growth  forms  at  the  bottom. 

On  agar  a  thick  grey-white  sticky  growth. 

The  bacilli  are  Gram-positive. 

To  stain  spores  heat  them  for  twenty  minutes  in  warm  carbol 
fuchsin. 


THE   EXAMINATION    OF   MICRO-ORGANISMS  617 

(Heat  a  penny  over  the  flame,  remove  it,  place  upon  it  the  slide 
witii  spores  and  stain.     Repeat  several  times.) 

(2)  The  Tetanus  Bacillus. 

Short  straight  slender  rod  with  rounded  ends,  slightly  motile  with 
man^'  flagella,  forms  spherical  spores  at  one  end,  giving  the  "  drum- 
stick "  appearance.     Gram-positive.     Not  acid-fast. 

A  strict  anaerobe.  Liquefies  gelatin.  In  glucose-agar  stab,  a 
feathery  radiated  growth  with  slight  gas  formation.  Spores  very 
resistant.  Nearly  pure  cultures  obtained  by  heating  ordinary  earth  to 
80°  C.  on  two  to  three  successive  days  and  then  preparing  agar  shake 
cultures. 

Produces  two  alkaloidal  toxins,  tetanotoxine  and  spasmotoxine, 
which  both  produce  convulsions.     Readily  destroyed  by  heat  and  light. 

Natives  bury  carcases  in  order  to  produce  this  toxin  for  arrow 
poison. 

(3)  The  Bacillus  oedematis  maligni  (Bacillus  septicus). 

A  motile  slender  rod  (4  jx  long),  with  several  flagellce.  Gram- 
negative. 

Stains  readily.  Forms  spores  in  a  central  position.  Tends  to  grow 
in  long  filaments.  A  strict  anaerobe.  Gelatin  liquefied  with  pro- 
duction of  foul  smelling  gas.     Blood  serum  liquefied. 

(4)  The  Bacillus  botulinus. 

Large  (4  to  6  /i),  with  rounded  ends,  slight  motility,  four  to 
eight  flagella,  forms  terminal  spores,  an  obligatory  anaerobe.  Gram- 
positive.  Does  not  curdle  milk,  ferments  glucose  with  production  of 
acid  and  gas,  lactose  not  fermented.  In  glucose  gelatin  yellowish- 
brown  translucent  colonies  are  formed  surrounded  by  a  liquefied  zone. 
Causes  botulism. 

(5)  The  Bacillus  welchii. 

A  long  (3  to  6  jx'),  thick  bacillus  in  ones,  chains  and  clumps,  often 
has  a  capsule,  forms  spores  only  in  serum  cultures,  strictly  anaerobic, 
Gram-positive.  Non-motile.  Licjuefies  gelatin  slowly,  produces  gas 
in  dextrose  and  lactose,  a  honey-combed  curd  in  milk  with  gas  in 
twenty-four  hours.  Cultures  are  stronglv  acid.  Found  in  septicaemic 
and  pyasmic  infections  of  the  gastro-intestinal  tract. 

The  important  ones  from  the  Coli  Group  are : — 

(i)  Bacillus  coli. 

(2)  The  capsulated  bacilli." 

(3)  The  bacillus  enteritidis  group. 

(4)  Bacillus  typhosus. 

(5)  Bacillus  dysenteric. 

All  are  as  a  rule  short,  stout  with  rounded  ends,  form  no  spores. 


6i8 


LABORATORY   HINTS 


Gram-negative.      Do   not   liquefy   gelatine.      On   gelatin   plates    form 
ithin,  irregular,  notched  colonies  (see  table  for  dififerentiation). 


Class 

Motility 

Glucose 

Lactose 

Litmus  paper 

Indol 
Production 

Neutral  red 

Typhoid  ba- 

Actively mo- 

Acid formed; 

No  action 

Permanent 

No  indol 

No  change 

cillus 

tile ;  8  to  12 
flagella 

no  gas 

acidity;  no 
other  change 

Intermediate 

Ditto 

Acid  and 

No  action 

Kirst  acid, 

No  indol 

Becomes 

or  Gartner 

gas  formed 

then  alkaline, 

as  a  rule 

yellow 

group 

no  other 
change 

Colon  group 

Feebly  mo- 

Ditto 

Acid  and  gas 

Permanent 

Indol 

Ditto 

tile ;   3  to  4 

formed 

acidity  with 

formed 

flagella 

curdling 

Dysentery 

Non-motile 

Acid  formed ; 

No  action 

First  acid. 

Sometimes 

No  change 

bacillus 

no  flagella 

no  gas 

then  usually 
becoming 
alkaline 

formed 

(1)  The  Bacillus  coll. 

Short  (2  to  4  fi)  rounded  ends,  sometimes  almost  oval,  three  to 
four  flagella,  feebly  motile,  no  spores.  Gram-negative.  It  never 
liquefies  gelatin,  produces  permanent  acidity  in  milk  which  is  curdled 
within  seven  days  at  37°  C.  Ferments  glucose  and  lactose  with  acid 
and  gas,  forms  indol,  a  thick  yellow-brown  growth  on  potato,  reduces 
nitrates.   • 

(2)  The  Capsulated  Bacilli. 

Bacillus  pneumoniae,  or  the  pneumo-bacillus  of  Friedlander. 

A  short  rod  (i  to  2  /a)  with  rounded  ends,  encapsulated,  frequently 
in  pairs,  non-motile,  non-sporing,  aerobic  and  facultative  anaerobic. 
Gram-negative.  (The  pneumococcus  is  Gram-positive.)  It  loses  its 
capsule  when  cultivated,  a  nail-shaped  growth  in  stab  gelatin,  milk 
slowly  coagulated. 

Bacillus  lactis  aerogenes,  non-motile,  does  not  ferment  dulcitol, 
milk  rapidly  curdled  with  formation  of  capsules,  forms  "  nail-head  " 
growth  in  gelatin. 

(3)  The  Enteritidis  Group. 

The  enteritidis  group  includes  such  as  Gartner's  bacillus  which 
causes  meat  poisoning  epidemics. 

The  pneumonic  group  such  as  bacillus  psittacosis  causing  epidemic 
pneumonia  in  parrots  and  a  fatal  broncho-pneumonia  in  man. 

The  paratyphoid  group  causing  paratyphoid  fever. 

The  non-pathogenic  group  (to  man),  as  the  bacillus  suicholeras  or 
hog  cholera  bacillus  and  the  Danysz's  bacillus  for  exterminating  rats. 

They  all  resemble  the  typhoid  bacillus,  morphologically  being 
Gram-negative,  activelv  motile,  multi-flagellate,  non-sporing,  but  they 


THE   EXAMINATION    OF   MICRO-ORGANISMS  619 

differ  in  cultures.     They  reduce  neutral  red,  do  not  curdle  milk,  pro- 
duce acid  and  gas  from  glucose,  do  not  attack  lactose. 

Litmus  milk  is  first  acid  then  alkaline. 

The  agglutination  test  is  often  necessary  to  differentiate  them. 

(4)  Bacillus  typhosus. 

Short  (2  to  4  ^),  thick,  rounded  ends,  no  spores  but  granules  and 
vacuoles  are  sometimes  seen.  Involution  forms  10  '  to  30  yu  on  repeated 
sub-culture  are  characteristic.  Aerobic  and  facultative  anaerobic. 
Gram-negative.  Not  killed  by  drying.  Direct  sunlight  kills  in  five 
ho'urs.  On  agar  a  thick  greyish-creamy  growth,  on  gelatin  a  thin 
white  growth  without  liquefaction,  turbidity  in  broth  with  some  deposit, 
milk  made  slightly  acid,  no  curdling,  ferments  glucose  with  acid  but 
no  gas,  lactose  not  affected,  neutral  red  not  affected,  forms  little  or  no 
indol.  Infects  humans  through  water,  shell-fish,  dust  and  air,  flies, 
vegetables,  soil,   milk  (dirty),   filters,   contact  with  carriers. 

(5)  The  Dysentery  Bacillus. 

Fifteen  tvpes  are  said  to  exist.  The  Flexner  and  the  Shiga-Kruse 
varieties  are  the  best  known. 

All  resemble  Bacillus  coli  and  typhoid  bacilli  in  morphology  and 
staining  reactions.  Generall}'  said  to  be  non-motile.  Grow  well  in 
milk  without  clotting,  with  acid  then  alkaline  reaction.  In  a  few  days 
ferments  glucose  with  acid  but  no  gas.  Agglutination  identifies  the 
variety. 

The  Flexner  type  ferments  mannitol  with  acid  but  no  gas. 

The  Shiga-Kruse  bacillus  has  no  action  on  this  polyhydric  alcohol. 

Other  important  micro-organisms  are  :  — 

The  Bacillus  diphtheriae. 

The  Klebs-Lofffer  bacillus  is  a  slender  (3  to  5  /^  )  non-motile,  non- 
sporing  rod  with  rounded  ends.  A  parallel  arrangement  is  common 
and  club-shaped  forms  are  frequent.     Not  killed  by  drying. 

Aerobic  and  facultative  anaerobic.  Shows  segmentation  on  staining 
with  Loffler's  blue.     Gram-positive.     Shows  growth  on  gelatin  with- 
out liquefaction,  rapid  growth  on  agar  and  blood  serum  at  blood  heat, 
does  not  coagulate  milk,  forms  acid  therein  but  no  gas. 

The  Bacillus  pestis. 

A  short,  thick  rod,  usually  linked  in  pairs,  like  a  cocco-bacillus. 
Gram-negative,  non-motile,  no  spores,  bipolar  staining.  Grows  best 
from  25°  to  20°  C.  Easily  killed  by  disinfectants,  cultures  lose  their 
virulence  quickly.  In  broth  with  a  little  butter  flocculent  tapering 
masses  of  growth  are  seen  depending  upon  the  oil  droplets  floating  on 
the  surface — Haffkine's  stalactite  growth. 

On  gelatin  a  thick  whitish  punctate  growth  without   liquefaction. 

It  does  not  coagulate  milk. 


620  LABORATORY    HINTS 

The  Staphylococcus  pyogenes  aureus. 

Occurs  as  a  diplococcus  in  grape-like  masses,  non-motile,  no 
spores.  Gram-posilive.  General  turbidity  in  broth,  liquefies  gelatin 
with  an  orange-yellow  sediment,  on  agar  and  blood  serum  a  pale,  then 
later  a  golden  streak  is  formed.  Staphylococcus  pyogenes  albus  pro- 
duces a  white  and  Staphylococcus  pyogenes  citreus  a  lemon-yellow 
growth  on  agar  and  blood  serum. 

The  Bacillus  pyocyaneus. 

A  small  bacillus  found  in  blue-green  pus,  very  motile.  Non- 
sporing.  Creamy  growth  on  agar  with  greenish  fluorescence,  liquefies 
gelatin  rapidly.  Gram-negative.  The  pigments,  pyocyanin  and  pyo- 
xanthin,  can  be  extracted  with  chloroform. 

The  Streptococcus  pyogenes. 

In  chains,  ten  to  fifteen  bacteria  in  pus,  thirty  to  forty  bacteria  in 
broth  cultures.  Gram-positive.  Grows  well  with  or  without  oxvgen. 
Produces  turbidity  in  broth,  but  growth  ceases  after  four  days  owing 
to  the  production  of  an  inhibitory  metabolic  substance.  Slow  growth 
on  gelatin  without  liquefaction.  Coley's  fluid  is  from  Streptococcus 
pyogenes  and  Bacillus  prodigiosus,  grown  together  for  two  weeks  and 
sterilized  by  heat  65°  C. 

The  Gonococcus. 

Small  coffee-bean  in  shape,  usually  in  pairs,  a  strict  parasite. 

Does  not  grow  on  ordinary  media,  but  can  be  cultivated  on  blood 
or  blood  serum  agar.  A  pure  culture  has  a  raised  greyish-white 
mulberry  appearance. 

The  Meningococcus. 

The  Diplococcus  intracellularis  meningitidis  is  Gram-positive. 

Grows  on  blood  agar  at  blood  heat,  occurs  within  the  pus  cells  as 
a  diplococcus,  produces  epidemic  cerebrospinal  meningitis  (or  spotted 
fever). 

The  Diplococcus  pneumoniae. 

Usually  seen  as  a  diplococcus,  but  sometimes  in  chains  of  pus. 

The  cocci  are  oval  or  lance-shaped  in  a  gelatinous  capsule. 

Gram-positive.     Grows  well  on  blood  serum,  but  not  readily  seen. 

Does  not  grow  well  on  gelatin.     In  cultivation  the  capsule  is  lost. 

No  growth  on  potato.     Produces  curdling  and  acid  with  milk. 

The  Micrococcus  melitensis. 

Small,  in  pairs  or  singly  or  short  chains  with  active  Brownian 
movement.  Slow  growth,  in  three  to  four  days  small  semi-transparent 
droplets  on  agar,  which  later  become  yellowish-orange.  On  gelatin 
a  dirty  white  streak  without  liquefaction.  Gram-negative.  It  occurs 
in  the  blood  and  milk  of  goats. 


THE   EXAMINATION    OF   MICRO-ORGANISMS  621 

The  Glanders  Bacillus. 

The  Bacillus  mallei  is  a  short  rod  (2-5    /a)  with  rounded  ends. 

Bipolar  or  beaded  in  stained  preparations,  no  spores. 

Non-motile,  but  active  Brownian  movement.  A  creamy  growth  on 
glycerine  agar,  does  not  liquefy  gelatin.  On  potato,  four  days,  looks 
like  drops  of  honey,  but  later  darkens  to  chocolate  colour,  but  the 
potato  remains  unstained.  Gram-negative.  Does  not  readily  stain  at 
all;  methylene  blue,  and  then  4  to  5  per  cent,  acetic  for  ten  seconds  is 
the  best  stain. 

The  Spirillum  cholerae  asiaticsB. 

Koch's  comma  bacillus  is  a  curved  rod  (2-.-;  ^)  vS-shaped  in  liquid 
media,  actively  motile,  one  flagellum,  no  spores,  desiccation  and  sun- 
light rapidly  fatal.  Gram-negative.  Readily  stained  with  aniline 
dyes,  grows  readily  on  most  media,  but  a  slight  alkaline  reaction  is 
necessary.     Forms  indol  rapidly,  creamy  growths  on  agar. 

General  turbidity  in  broth  and  H2S  in  both.  Occurs  in  flakes  in 
a  "fish  in   stream"   position.      For  bacterial   diagnosis,   see  Cholera. 

The  Finkler-Prior  spirillum  may  be  confounded  with  it.  These 
are  thicker  and  longer  than  the  Koch's  comma  bacillus,  and  it  can  be 
differentiated  by  the  cultural  reactions:  — 

Cultural  Characters  KocK s  Comma  Bacillus  Vibrio  Proteus 

(Finkler-Prior  Spirillum) 

Gelatin  stab  culture         ...     Slow  liquefaction Rapid  liquefaction 

Potato  at  37°C Slow   light  greyish  brown  Rapid  slimy  yellow  growth 

growth     ... 

Peptone  water       Indol      reaction      marked  Indol    reaction    feeble  or    nil 

within  twelve  hours      ...  in  three  days 

t 

TO  PREPARE  CULTURES. 

For  nutrient  media,  test-tubes,  Petri  dishes  and  other  vessels  are 
used. 

Wash  all  with  25  per  cent.  HCl,  rinse  well  with  water  and  drain, 
rinse  with  alcohol  and  dry,  plug  test-tubes  with  cottonwool,  sterilize 
at  140°  C. 

The  common  media  are  :  — 

Beef  Broth. 

Use  I  lb.  of  beef  steak,  free  from  fat  and  connective  tissue,  mince, 
add  1,000  c.c.  of  water,  boil  and  stir  well  for  thirty  minutes.  Strain 
through  muslin,  add  water  up  to  1,000  c.c,  add  sodium  chloride, 
5  grm.,  and  peptone,  10  grm.,  boil  for  five  minutes,  carefully  neutralize 
with  sodium  hydrate  solution,  make  it  slightly  alkaline  to  litmus,  then 
boil  for  ten  minutes,  shaking  well,  filter  it  into  flasks  plugged  with 
sterile  cottonwool. 


622  LABORATORY   HINTS 

Glucose  and  Lactose  Broth. 

To  each  loo  c.c.  of  above  i  to  2  grm.  of  line  g"lucose  or  lactose. 
This  is  used  for  anaerobic  bacteria. 

Nutrient  Gelatin. 

To  one  litre  of  acid  beef  broth  add  100  grm.  of  gelatin,  10  grm.  of 
peptone,  and  5  grm.  of  salt.  Place  in  water  bath  until  solution  is 
clear,  make  faintly  alkaline  with  NajOH,  cool  to  50°  C,  add  the  white 
of  an  egg,  after  stirring  steam  for  an  hour,  filter,  and  run  into  test- 
tubes.     Sterilize  for  fifteen  minutes  on  three  successive  days. 

Agar-agar. 

15  grm.  of  powdered  agar-agar  well  boiled  with  one  litre  of  nutrient 
broth  for  two  hours  until  dissolved,  replace  the  water  .lost,  see  that  it 


Hot-air  sterilizer. 


is  faintly  alkaline,  clear  with  egg-albumen,  filter  through  a  "  Chardin  " 
filter  paper.  It  remains  solid  at  40°  C,  and  only  melts  completely 
at  90°  C. 

Glucose  and  Lactose  Peptone  Waters. 

10  grm.  of  peptone  and  5  grm  of  salt  dissolved  in  1,000  c.c.  of  dis- 
tilled water,  boil  well,  neutralize  in  the  usual  way,  boil  and  filter,  run 
into  tubes  and  sterilize  thrice. 

Add  I  to  2  per  cent,  of  glucose  or  lactose  to  this,  tinge  it  with 
litmus  solution  to  indicate  production  of  acid  and  alkaline. 

It  is  a  useful  media  for  determining  the  fermentative  power  of 
organisms.     This  medium  is  best  placed  in  Durham's  miniature  test- 


THE   EXAMINATION    OE   MICRO-ORGANISMS 


623 


tubes,    which    will    become    filled    during    the    sterilization.      During 
fermentation  these  become  gas-holders. 

Blood  Serum. 

Take  blood  from  the  jugular  vein,  operation  wound,  or  placentc'e 
with  aseptic  precautions,  let  it  stand,  draw  off  with  large  pipette  into 
test-tubes  set  on  a  slant. 

The  serum  sets  after  heating  in  hot-air  sterilizer  to  65°  C 


Hearson's  incubator,  working  with  petroleum  lamp. 

Gelatin  Plate  Cultures. 

Place  three  test-tubes  containing  nutrient  gelatin  in  boiling  water 
until  liquid,  then  cool  to  40°  C.  Introduce  into  tube  a  sterilized 
platinum  loopful,  a  mere  trace,  of  a  culture  of  the  organisms  to  be 
examined,  and  mix  well.  Sterilize  the  loop,  and  put  one  loopful  from 
tube  I  to  tube  2  and  shake,  put  two  loopfuls  into  tube  3  from  tube  2. 
Pour  the  contents  of  each  into  Petri  dishes.  In  these  the  colonies  may 
be  seen  and  counted  without  removing  the  lid. 

Agar  plates  are  prepared  in  the  same  way,  but  it  is  necessary  to 


624  LABORATORY   HINTS 

work  more  quickly  as  the  agar  soon  solidifies  and  the  organisms  are 
not  evenly  distributed.  When  the  agar  has  set  invert  dishes  to 
prevent  water  of  condensation  spoiling  colonies. 

"  Streak  "  Cultures. 

An  oblique  slope  of  agar  or  nutrient  gelatin  in  a  test-tube  is  taken, 
and  with  a  sterilized  platinum  loop  a  trace  from  the  culture  is  drawn 
up  the  slope. 

"Stab"  Cultures. 

A  test-tube  of  solid  media  is  taken,  and  the  straight  platinum  wire 
with  the  growth  on  the  tip  is  introduced  down  the  centre  of  the  medium. 

"  Shake  "  Cultures. 

Liquefy  the  gelatin  in  a  test-tube  by  putting  it  in  a  beaker  of  water 
at  40°  C,  and  inoculate  the  medium  with  the  organism.  Gently  mix 
to  distribute  the  organisms;  gas  producing  organisms  form  bubbles. 

"Anaerobic"  Cultures. 

Glucose  agar  or  gelatin  is  most  frequently  used.  A  tube  three- 
quarters  full  is  kept  in  boiling  water  for  five  minutes  to  soften  the 
medium  and  expel  the  oxygen.  After  the  stab  is  made,  warm  the  top 
of  the  medium  to  seal  the  needle  track.  For  fluid  media  place  thereon 
a  layer  of  olive  oil,  and  then  inoculate  with  a  sterile  pipette. 

In  diflFerentiating  growth  note: — 

If  the  colonies  are  separate,  rounded,  minute  or  large  indefinable 
masses.  Plague  bacteria  grows  in  small  rounded  masses,  but  Coli 
form  one  creamy  mass.  Notice  if  any  colour  is  produced  and  if  the 
medium  is  stained  as  with  Bacillus  pyocyaneus. 

Does  the  growth  spread  aw^ay  from  the  line  of  inoculation,  and  if 
so,  what  kind  of  an  edge  does  it  form  ?  Is  gelatin  liquefied,  broth 
rendered  turbid?  Does  a  scum  form  on  the  surface?  Is  the  deposit  at 
the  bottom  ?  Does  it  produce  acid  or  gas  or  both  in  a  sugar  medium  ? 
Is  milk  clotted  or  acid  formed  in  it?  Will  it  grow  on  potato,  and  if 
so,  is  any  colour  produced  ? 

THE   PREPARATION  OF  SECTIONS. 
(1)  Fixing  the  Tissues. 

Place  the  piece  of  tissue  in    10  per  cent,   formalin,   twelve  to 

twenty-four  hours. 
Wash  in  running  water  and  then  proceed  to  harden  it. 
After  it  is  hardened  the  tissue  must  be  prepared   for  section 

cutting. 
This  is  by  freezing  or  embedding  in  paraffin. 


THE  PREPARATION   OF  SECTIONS 


625 


(2)  Hardening  of  Tissues. 

Place  the  tissue  in  three  strengths  of  alcohol  successively, 
viz.  :  50  per  cent.,  75  per  cent.,  and  absolute,  the  tissue 
remaining  in  each  twenty-four  to  forty-eight  hours. 

If  one  desires  to  keep  the  tissue,  place  in  70  per  cent,  alcohol. 

Cut  from  the  tissue  small  blocks  10  to  20  mm.  square  and 
immerse  in  alcohol. 

(3)  Freezing  of  Tissues. 

Place  the  blocks  of  tissue  in  an  open  vessel  and  allow  water 


Microtome,  Cathcart's,  with  spray  bellows. 


to  run  into  it  for  two  hours  to  remove  the  alcohol,  then  soak 
in  a  syrupy  m.ucilage  of  gum  acacia  with  a  little  carbolic  acid. 

Place  it  on  the  plate  of  the  freezing  microtome,  a  little 
mucilage  is  added  and  the  whole  frozen.  The  sections  are 
cut  by  the  knife  moistened  with  A\ater  and  brushed  into 
tepid  water  with  a  camel-hair  brush. 

These  can  now  be  stained  or  preserved  in  70  per  cent,  alcohol. 

(4)  Embedding  of  Tissues. 

After  hardening  place   in   absolute  alcohol   twelve   to   twenty- 
four  hours,  then  in  pure  xylol  for  the  same  time,  then  in  a 


626  LABORATORY   HINTS 

bath    of    melted   paraffin    wax    six    to    eighteen    hours ;    the 

paraffin   must   be   kept   melted.      The   paraffin   that    is   most 

useful   for  all  purposes   is   that   having   a   melting  point   of 

50°  to  60°  C. 
Skin  tissues  become  friable  if  kept  long  in  the  melted  paraffin. 
After  impregnation  of  the  tissue  it  must  be  embedded. 
Pour  a   little  paraffin   wax   into  a  small   (pill)  box,    place   the 

block    of   tissue    in    the   centre   and    fill    the   box  with    wax. 

When  set   remove   the  box  and  attach   to  the  plate  of  the 

microtome. 

(5)   Mounting  Sections  on  Slides. 

Place  section  in  a  dish  of  warm  water  so  that  the  paraffin  is 

softened  but  not  melted,  then  the  sections  become  flat. 
Introduce  a  slide  into  the  water  under  the  section  and  raise  it 

out  of  the  water,  adjusting  it  with  a  needle. 
Dry  in  warm  incubator  for  two  hours. 
If  the  sections  are  thick  it  is  preferable  to  smear  the  slide  first 

with    egg    albumen    mixture    to    make    the    section    adhere 

sufficiently  for  staining, 

For  individual   sections  place  a   few  drops  of  water  on  the 

slide,    float   section    in    it,    and    warm    over   a   flame   until   it 

straightens  out. 
Pour  off  the  water  and  the  section  will  adhere. 

To  Stain  Sections. 

Remove  paraffin  with  xylol  and  the  xylol  with  spirit  and  the  spirit 
with  water.     This  is  unnecessary  if  it  is  not  a  paraffin  section. 

Stain  with  haematoxvlin  two  and  a  half  minutes,   and  flush  with 
water  until  blue. 

Stain  with  eosin  ten  seconds  and  wash  with  water. 
Treat  with  spirit  to  remove  water,  then  with  clove  oil. 
Treat  with  xylol  and  mount  wilh  Canada  balsam. 
Never  let  the  section  dry. 

To  tell  if  completely  dehydrated  when  using  clove  oil  place 
on  a  dark  slab,  when  it  will  appear  milky  as  long  as  water 
remains  in  the  section. 

To  show  Parasites  and  Bacteria. 

Remove  the  paraffin  with  xylol,  spirit  and  water  as  above. 

Stain  with  strong  carbol-thionin  ten  minutes. 

Pour  off  and  blot  lightly. 

Treat  with  spirit  rapidly,  two  dashes  only. 

Treat  with  oil  of  cloves  until  transparent. 

Treat  with  xylol  and  mount  with  Canada  balsam. 


THE  PREPARATION   OF  SECTIONS  627 

Van  Gieson's  Stain. 

Treat  as  above  to  remove  paraffin. 

Stain  with  hjematoxylin  fifteen  to  twenty  minutes  and  blue  well  in 
tap  water. 

Stain  with  van  Gieson  half  to  one  minute  (picric  acid  i|  per  cent. 
of  acid  fuchsin). 

Treat  with  spirit,  oil  of  cloves,  xylol  and  mount. 

The  haematoxylin  stains  the  nuclei  and  parasites  blue. 
The  picric  acid  stains  the  protoplasm  of  the  cells  yellow. 
The  fuchsin  stains  the  fibrous  tissue  red. 

To  show  Malarial  Parasites  in  the  Brain. 

Remove  the  paraffin.  Stain  with  haematoxylin  twenty  minutes  and 
blue  well  in  tap  water. 

Treat  with  acid  alcohol  one  to  four  seconds,  wash  well. 
Treat  with  spirit,  oil  of  cloves,  xvlol  and  mount. 

To  Embed  in  Celluloidin. 

Celluloidin  is  a  product  of  gun  cotton  and  looks  like  glass 
cotton . 

It  must  be  packed  in  water  for  transit. 

It  is  a  gummy  transparent  substance,  and  is  useful  for  holding  the 
brain  tissue  and  the  malarial  parasites  together  in  subtertian  cases. 

It  must  be  dried  before  using. 

Place  the  section  in  spirit  twenty-four  hours,  in  another  solution 
of  spirit  for  the  same  period,  in  absolute  alcohol  twenty-four  hours,  in 
alcohol  and  ether  for  twenty-four  hours,  in  thin  celluloidin  twentv- 
four  hours. 

Pour  some  thick  celluloidin  on  a  wooden  block  and  place  the  tissue 
on  it;  leave  it  in  the  air  for  a  few  minutes. 

Place  in  60  per  cent,  spirit  to  harden  it  until  it  is  cut. 

To  mount  and  stain  the  Section. 

Place  in  a  watery  haematoxylin  stain  twelve  minutes.  (Watch 
glasses  are  the  best  for  these  processes.) 

Wash  and  blue  well  in  tap  water. 

Treat  with  acid  alcohol  until  red,  five  seconds. 

Wash  well  and  stain  Vvith  alcoholic  eosin  three  to  four 
minutes. 

Pass  through  three  baths  of  spirit. 

Clear  in  carbol  xylol  and  mount. 

A  low  power  shows  the  brain  capillaries  plainl\'  because  of  the 
malarial  pigment  present  in  subtertian  cases. 


628  LABORATORY   HINTS 

MALARIAL    PIGMEXT  :    WHERE    IT    IS    AND    HOW   TO 

LOOK    FOR    IT. 

This  pigment  is  found  in  the  parasites,  rarely  in  the  polymorpho- 
nuclears and  in  large  mononuclears.  When  in  the  latter  it  is 
])athognomonic  of  malaria.  The  pigment  is  carried  by  the  cells  to  the 
liver  and  spleen.  The  endothelial  cells  of  the  capillary  also  take  it 
up  and  may  then  become  detached.  If  pigment  is  found  elsewhere  it 
is  not  malaria.     The  pigment  is  nearly  always  intracellular. 

The  mononuclears  soon  give  it  up  again,  so  that  to  find  these  cells 
carrying  it  indicates  that  malaria  was  progressing  at  Jhe  time. 

In  the  liver  it  is  found  in  the  small  cells  of  the  connective  tissue 
type  with  a  dark  staining  nucleus  which  penetrates  between  and  into 
the  liver  lobules.  The  containing  cell  becomes  degenerate,  the  nucleus 
stains  faintly,  and  the  pigment  appears  in  larger  clumps. 

Later,  the  pigment  alone  remains,  lying  in  the  connective 
tissue. 

This  latter  stage  is  reached  from  the  twentieth  to  the  thirty-second 
day,  so  that  from  the  examination  of  the  liver  one  can  tell  how  long 
the  malarial  process  has  been  going  on,  and  it  indicates  that  the  liver 
was  active  at  the  time  of  death. 

In  the  spleen  pigment  is  always  present,  chieflv  in  the  macro- 
phages, which  may  give  a  dark  appearance  to  the  organ  on  section 
according  to  the  number  of  malarial  attacks  and  the  amount  of  pigment 
deposited. 

A  slaty-black  colour  is  almost  diagnostic. 

Malarial  pigment  consists  of  :  — 
(i)  Melanin,  which  is  diagnostic. 

(2)  H^emosiderin,  not  diagnostic. 

(3)  Iron-bearing  granules,   not  diagnostic. 

Melanin  contains  iron,  but  in  such  firm  combination  that  it  does 
not  give  the  iron  reaction.  It  is  insoluble  in  acids,  soluble  in  alkalies, 
insoluble  in  alcohol. 

H^emosiderin  is  insoluble  in  acids  and  alkalies,  but  soluble  in 
alcohol. 

It  does  not  require  staining  to  be  seen.  It  is  said  not  to  contain 
iron.     Carbol  thionin  stains  it  violet. 

The  iron-free  granules  contain  iron  in  inorganic  combination,  so 
will  give  the  reaction  for  free  iron.  The  more  acute  the  hsemolytic 
process,  the  more  numerous  the  iron  granules ;  the  more  chronic  the 
process,  the  more  numerous  are  the  yellow  granules. 

In  blackwater  fever  there  is  much  blue  pigment;  and  in  anky- 
lostomiasis much  yellow  pigment.  The  haemosiderin  and  the  iron- 
free  granules  are  seen  in  any  disease  causing  haemolysis,  as  pernicious 


THE    TRICHOMYCETES  629 

anemia,   blackwater,  &c.     They  are  found  in  the  true  secreting  cells 
Hning  the  first  portion  of  the  convoluted  tubules  of  the  kidney. 
Rarelv  the  three  kinds  may  be  found  in  the  same  cell. 

To  show  the  three  Pigments: — 

Stain  with  carmine  ten  minutes. 

Stain  with  acid  alcohol  three  minutes. 

Stain  with  potassium  ferrocyanide  five  minutes. 

Stain   with   acid  alcohol   until   blue. 

Treat  with  spirits,  oil  of  cloves,  xylol  and  mount. 

This  is  a  chemical  process,  and  Prussian  blue  is  formed. 

The  potassium  ferrocyanide  and  acid  alcohol  can  be  repeated 
several  times  until  the  part  is  sufficiently  blue. 

The  pigment  in  the  lung  is  chiefly  carbon ;  treat  the  section  with 
an  alkali  if  suspicious,  carbon  will  not  be  dissolved,  but  melanin  will. 

The  pigment  in  the  skin  of  the  dark  races  is  not  like  that  of  malarial 
pigment.  It  contains  no  iron  whatever,  and  is  dissolved  in  weak  acids, 
which  distinguishes  it  from  true  melanin.  Tattoo  pigment  is  deposited 
very  irregularly,  and  can  be  diagnosed  at  once  under  the  microscope. 


Between  bacteria  proper  (Schizomycetes)  and  the  moulds  (Hypho- 
mycetes)  comes  a  group  known  as — 

THE  TRICHOMYCETES. 

This  group  is  divided  into  :  — 
The  leptothrix,  no  branching. 
The  cladothrix,  false  branching. 
The  streptothrix,  true  branching. 

The  Actinomyces. 

This  ray  fungus  is  a  streptothrix  consisting  of  filaments,  cocci  and 
clubs.  The  filaments  are  long  and  thin,  interlacing  in  the  centre  of 
the  colony  forming  a  network.  In  older  filaments  the  protoplasm  is 
broken  up  into  coccoid  bodies  which  may  break  out  from  the  sheath. 
The  clubs  are  involution  forms  perhaps  produced  by  resistance  of  the 
tissues. 

In  actinomyces  from  human  tissues  :  — 

The  threads  are  Gram-positive,  the  clubs  Gram-negative,  but  from 
cattle  the  threads  are  Gram-negative  and  the  clubs  are  Gram-positive. 

Man  may  be  injected  with  the  bovine  type.  In  artificial  media  the 
clubs  are  not  found.     Il  grows  well  on  potato  and  glycerine  agar. 

On  potato  it  forms  a  thick,  grey,  raised,  wrinkled  growth  of  sulphur 
yellow  or  light  chocolate  colour. 

It  causes  actinomvcnsis  in  man  and  cattle. 


630  LABORATORY    HINTS 

Streptothrix  madura. 

This  fungus  produces  in  Cyprus,  India,  South  America  and  Egypt 
the  white  form  of  madura  disease  or  mycetoma,  which  is  much  more 
common  than  the  black  or  red  varieties.  It  does  not  form  yellow  or 
black  pigments  in  cultures,  and  does  not  liquefy  gelatin.  It  is  not 
infective  for  rabbits.     The  clubs  do  not  stain  by  Gram. 

Stain  with  hsematoxylin  and  acid  or  carbol  thionin. 

THE  HYPHOMYCETES. 

The  moulds  or  mycelial  fungi  are  multicellular  organisms  composed 
of  filaments  which  interlace,  forming  a  mass  of  mycelium. 

(1)  Mucorinal. 

The  end  of  a  filament  or  hypha  swells  into  a  knob  around  which  a 
spherical  seed  capsule  forms.  When  ripe,  the  spores  burst  the  enclos- 
ing membrane  and  thus  become  free.  It  occurs  in  any  decomposing 
material  and  in  man  ma}-  occur  in  the  ear,  old  abscesses  and  bron- 
chiectatic  cavities. 

(2)  Aspergillinae. 

The  heads  of  the  filaments  are  covered  with  a  number  of  spore 
carriers  (sterigmata),  each  sterigmata  bears  a  chain  of  spores. 

They  may  invade  the  lung,  blocking  up  the  acini,  giving  rise  to 
symptoms  much  like  phthisis. 

(3)  Penicilliacese. 

The  filaments  are  branched,  from  these  basidia  arise  the  sterigmata 
from  which  in  turn  chains  of  spores  arise.  Thev  will  soon  overrun 
any  exposed  agar  plate. 

Penicillium  glaucum  is  the  commonest  mould  and  is  seen  on  moist 
bread,  damp  boots,  &c.,  as  a  bluish-green  fur,  giving  off  a  musty  odour. 
To  mount  moulds  remove  the  thin  layer  of  fat  that  normally  covers 
them,  with  alcohol  and  a  little  ammonia.     Then  mount  in  glycerine. 

They  can  be  stained  with  Loffler's  methylene  blue,  which  stains  the 
mycelium  and  livph^e,  the  spores  remaining  unchanged. 
Another  method  of  showing  moulds  is  to  :  — 

Stain  with  aniline  gentian  violet,  five  minutes. 
Pour  off,  blot,  treat  with  Gram's  iodine,  two  minutes. 
Treat  with  aniline  oil  and  iodine   until   differentiation   is  com- 
plete, about  fifteen  minutes. 
Treat  with  xylol  and  mount  in  Canada  balsam. 

Ringworm. 

This  is  a  kind  of  mould.  It  has  the  power  of  living  on  the 
keratinized  products  of  skin  which  it  breaks  up  and  digests. 


THE   BLASTOMYCETES  631 

Most  forms  disappear  before  the  human  host  has  reached  twenty 
years  of  age. 

(i)  Microsporon  andouini. 

Met  \\\t\]  in  cliildren.     Xever  attacks  the  scalp  of  aduUs.     Never 
affects  the  beard  and  nails.     Very  intractable.     It  occurs  as 
a  whitish  sheath  around  the  stumps  of  broken  hairs.     They 
are  round  or  oyoid  spores,  3  to  4  /Lt. 
(2)  Trichophyton   megalosporon. 

The    endothrix   variety    is    exclusively    of    human    origin  :    the 

spores  are  seen  in  the  interior  of  the  affected  hairs. 
The  ectothrix  variety  which  affects  the  beard  and  nails  is  derived 
from  animals,  the  spores  lying  on  the  exterior  of  the  hair. 
The  spores  are  large,  4  to  12  m.  To  facilitate  examination 
soak  the  hair  in  10  per  cent,  caustic  potash  and  then  alcohol 
and  ether  as  for  moulds. 

THE  BLASTOMYCETES. 

These  yeasts  are  round  or  oval  unicellular  organisms  having  hyaline 
protoplasm  in  healthy,  and  granular  protoplasm  in  old  cells,  surrounded 
by  a  wall  of  cellulose. 

The  torulas  multiply  by  budding. 

The  saccharomycetes  by  budding  and  spore  formation. 

Spores  are  formed  when  the  food  materials  are  exhausted. 

They  must  have  moisture  and  plenty  of  fresh  air,  temperature  above 
25°  C.  is  best  while  fermenting  nutrient  liquids  facilitate  the  formation 
of  spores. 

S.  cerevisias. 

There  are  two  typical  brewery  yeasts,  the  typical  English,  a  "  top  " 
fermentation  variety,  and  the  yeast  of  the  Continental  lager  beer,  a 
"  bottom  "  fermentation.  The  "  top  "  and  "  bottom  "  are  also  known 
as  the  "  high  "  and  "  low  "  as  they  develop  in  high  and  low  tempera- 
tures respectively.  They  are  8  to  9  /a  in  diameter.  Three  to  four 
spores  form  in  one  mother  cell. 
There  are  "  wild  yeasts  "  as  :  — 

5.  pastorianiis.      There  are  three  varieties  with   peculiarly   shaped 

cells    and    having    two    to    four    spores    in    each 
mother  cell 
,,  No.  I  is  a  bottom  form  and  causes  a  disagreeable 

smell  and  a  strong  bitter  taste  in  beer. 
,,  No.  2  is  a  feeble  top  form  of  little  importance. 

,,  No.  3  is  a  dangerous  "  top  "   form  causing  tur- 

bidity  and   disease. 
Bulgarian  sour  uiilk  is  used  for  therapeutic  purposes. 

40 


632  LABORATORY    HINTS 

A  yeast  attacks  tlie  milk  sugar  after  lactic  acid  has  been  formed, 
inhibits  the  gro\\th  of  pathogenic  and  putrefactive  bacteria  and  im- 
proves tiie  taste.  The  yeast  may  get  the  upper  hand  and  carry  the 
fermentation  too  far. 

Pathogenic  ycasls  cause  blastomycetic  dermatitis  as  sometimes  seen 
in    man. 

They  have  also  been  recovered  from  tumours,  lung  diseases,  sprue 
and  dysentery  cases. 

To  Stain  Yeasts. 

Use  Gram  or  an}-  :?imple  stain. 

Remember  that  they  stain  mahogany  brown  and  not  gentian  violet 
with  Gram. 

THE  EXAMINATION  OF  F.ECES. 
MACROSCOPIC. 

This  is  a  very  necessary  routine  practice  in  the  tropics. 

Note  the  number,  bulk,  colour,  odour,  consistency  and  the  reaction 
of  the  stools. 

Note  the  presence  or  absence  of  gaseous  fermentation. 

The  presence  or  absence  of  blood,  mucus,  pus  and  their  degree  of 
admixture  whh  the  stool. 

Any  visible  £inimal  parasites,  undigested  food  materials,  &c. 

Remember  that  mucus  from  the  small  intestine  is  stained  with  bile 
and  is  not  frequent) \'  seen,  but  mucus  is  common  from  the  lower  bowel 
and  may  be  caused  by  anything  tliat  sets  up  inflammation  in  it  such 
as  bilharzia,  chronic  ulcerations  as  from  ulcerated  haemorrhoids, 
nic'ilignant  and  granulomatous  gro^\•ths  and  chronic  dysentery. 

In  acute  dysentery  the  mucus  is  usually  clear,  not  mixed  with 
faecal  matter,  and  may  be  streaked  with  bright  red  blood. 

If  it  comes  awa}-  in  condensed  hard  masses  with  much  debris  and 
epithelial  tissue  ^\ith  pus  the  affection  is  usually  of  the  rectum. 

If  bowel  casts  are  passed  (membranous  colitis)  they  may  be  twisted, 
these  should  be  floated  out  in  water  as  they  may  resemble  worms. 

If  bright  red  blood  is  passed  it  does  not  necessarily  mean  that  it 
has  come  from  tiie  rectum,  such  mav  come  from  the  small  intestines. 

If  the  stools  are  numerous,  pale,  frothy,  it  is  suspicious  of  sprue. 

Remember  that  in  the  tropics  the  caecum  and  upper  part  of  the 
colon  may  be  ulcerated  acutely  and  extensively  without  passage  of 
either  mucus  or  blood  or  with  tenesmus.     Such  may  be  rapidly  fatal. 

Remember  that  rice  and  plantain  eating  peoples  pass  much  larger 
stools  normally  tlian  do  meat  eating  peoples.  The  people  of  the  East 
eat  excess  of  carboh^-drate  food  to  obtain  sufBcient  protein. 


THE   EXAMINATION    OE    FJECES  633 

Europeans  in  the  tropics  give  an  average  stool  per  diem  of  130  grni. 

Natives  give  an  average  stool  of  2t,t,  grm.  per  diem. 

The  reaction  of  a  normal  stool  is  nearly  neutral  to  litmus,  acid  on 
fasting,  faintly  alkaline  when  taking  milk.  In  most  cases  of  diarrhoea 
they  are  decidedly  alkaline.  All  stools  should  be  examined  as  soon 
as  possible  after  being  passed. 

Macroscopic  mucus  usuall}'  means  catarrh  in  the  large  intestine. 

Microscopic  mucus  usually  means  catarrli  in  the  small  intestine. 

Earth  eaters  pass  pale  stools  which  may  in  this  respect  resemble 
obstructive  jaundice.  Those  who  eat  coal-dust  and  take  iron  or  bis- 
muth have  blackish  stools  which  may  resemble  mekena.  The  stools 
are  dark  blue  after  taking  metlu'lene  blue  and  brick  \'el1()\\-  after 
ipecacuanha. 

Bile  acids  are  recognized  by  Pettenkofer's  reaction. 

Mix  a  little  fiscal  matter  with  a  little  sugar  on  a  \\hite  dish,  add  a 
little  HsSOj.     A  crimson  colour  indicates  the  presence  of  bile  acids. 

To  Estimate  Nitrogen. 

Weigh  a  portion  of  fajcal  material. 

Add  20  c.c.  of  ^^  H2SO4  to  prevent  loss  of  ammonia. 

Dry   in   a   water  bath. 

Complete  desiccation  in  a  drying  chamber  at  10°  C.  over  H.SO,. 

Weigh  out  I  grm. 

Mix  with  25  c.c.  of  strong  ILSOi  and  i  grm.  of  sodiimi  h\])(v 
phosphate. 

Permit  to  stand  four  hours,  then  boil  cautiously. 

The  nitrogen  now  is  converted  and  ammonium  sulphate  is  formed. 

Allow  to  cool. 

Add  600  c.c.  of  water. 

Add  sodium  hydrate  solution  till  strongly  alkaline. 

Add  a  few  pieces  of  granulated  zinc  to  prevent  bumping. 

Distill  this,  passing  it  into  ^-^   H2SO4. 

Some  of  the  acid  is  neutralized  by  the  ammonia. 

Titrate  the  H0SO4  to  estimate  the  amount  of  the  ammonia  distilled 
over. 

To  Estimate  Fat. 

Dry  faeces  over  H2SO4. 

Treat  with  i  per  cent,  of  HCl  to  split  up  the  soaps. 

Add  ether  to  dissolve  fat. 

Add  more  ether  and  pour  off  and  add  to  former. 

For  bile  pigments,  bilirubin  and  biliverdin  employ  :  — 

(i)  Schmidt's  reaction. 

Add  to  faeces  a  saturated  solution  of  Hg  perchloride. 

A   bright  green   indicates  their   presence. 


034  LABORATORY    HINTS 

(2)  Giuelin's  reaction. 

Add  a  few  drops  of  yellow  nitric  acid  to  faeces. 
A  display  of  colours  including  green   is  positive. 

(3)  Huppert's  test. 

Add  slaked  lime  suspended  in  water  to  the  faeces. 
Filter,  wash  and  dry  the  precipitate. 
Make  an  extract  with  hot  alcohol  and  a  little  HoSOj. 
Bile  pigment  gives  a  green  colour. 
A  complete  absence  of  red  or  green  colouring  shows  absence  of 
bile  when  icterus  is  present.     When  the  latter  is  not  present  it  indicates 
temporary  suspension  of  bile  secretions.     In  fresh  brown  stools  giving 
no  red  coloration  there  is  usually  intestinal  decomposition. 

When  green  colouring  is  macroscopic  it  indicates  too  rapid  a 
passage  through  the  colon. 

Urobilin  is  ahvays  present  in  small  quantities  0*03  to  o"o6  grm. 
per  diem.  Any  h^emolytic  disease  increases  the  amount,  especially 
malaria.     In  subtertian  it  may  go  up  to  I'yi  grm.  or  more. 

It  is  one  of  the  final  products  of  destroyed  hb.  The  smell  is  due 
chiefly  to  indole  and  skatol.  Food  materials  are  absorbed  principally 
in  the  latter  half  of  the  small  intestine.  In  the  event  of  increased 
peristalsis  or  catarrh  of  this  part  the  contents  are  hurried  through 
without  benefiting  the  patient.  Water  is  absorbed  from  the  large  gut, 
increased  peristalsis  or  inflammation  hastens  the  contents  through  and 
gives  loose  stools,  while  diminished  peristalsis  or  constipation  from 
any  cause  means  hard  fseces  due  to  their  remaining  too  long  in  the 
colon  and  too  much  water  being  absorbed. 

The  water  in  an  average  stool  is  75  per  cent.  Weigh  before  and 
after  drying. 

Dry  over  H2SO4  as  volatile  substances  are  present  and  do  not  heat 
over  60°  C. 

Evaporate  ether  from  bath. 
Weigh  residue  =  total  fats. 

To  Examine  for  Macroscopic  Parasites. 

Place  the  stool  in  a  muslin  or  fine  wire  gauze  strainer,  add  water 
and  stir  well. 

Repeat  with  a  finer  mesh  each  time  and  use  fresh  water. 

The  entozoa  are  readily  found. 

For  diagnosing  helminths  and  amoebae  see  section  on  :  "  Diseases 
due  to  Helminths  "  and  "  Amoebic  Dysentery." 

MICROSCOPIC. 

Use  water  with  firm  stools,  but  as  little  water  as  possible.  Cover 
with  a  cover-slip  and  spread  out  the  material  by  pressure  on  the  slide. 

To  distinguish  mucus  from  connective  tissue  add  a  drop  of  acetic 
acid  :   fibrous  tissue  is  dissolved  and  mucus  is  more  distinct. 


THE    EXAMINATION    OF    FJECES  635 

Muscle    fibres   looking  like   brown   splinters   of   wood   will    indicate 
the  powers  of  protein  digestion  in  the  small  intestines. 

Connective    tissue    indicates    gastric    indigestion    and    that    organ 
should  be  minutely  examined. 

A  normal  stool  contains  23  per  cent,  of  fat  of  the  dry  substance, 
slight  variations  from  this  are  unimportant ;  a  morbid  increase  gives  a 
clay  coloured  sour  copious  stool,  and  the  sebacic  acid  flocculi  in  a  cold 
acetic  acid  preparation  are  much  increased  as  are  also  neulral  fat  drops, 
salts  of  lime  and  soap  crystals.  If  bile  is  absent  and  fat  increased  the 
disease  is  in  all  probability  in  the  biliary  duct  system.  If  \\ith  excess 
of  fat  there  are  muscle  fibres  and  hydrobilirubin  present  and  mucus 
is  absent  the  pancreas  is  the*  seat  of  the  disease.  When  biliary  and 
pancreatic  disorders  are  excluded  the  excess  of  fat  may  be  due  to  severe 
intestinal  disease  such  as  tuberculosis,  amyloid  disease  or  tabes 
mesenterica. 

Errors  in  the  examination  of  faeces  are  not  uncommon. 

Banana  fibres  may  be  mistaken  for  tapeworms,  especially  T.  nana 
and  T.  diniinuta,  owing  to  the  fact  that  they  are  made  up  of  segments 
resembling  tapeworm  strobilje. 

Orange  debris  resembles  certain  trematodes,   liver  flukes,  &c. 

Celery  shreds  may  be  mistaken  for  hookworms. 

Oatmeal  may  simulate  the  segments  of  worms. 

Undigested  pollen  grains  might  be  mistaken  for  eggs. 

The  ascus  of  a  mould  mistaken  for  an  egg-shell. 

The  oncospheres  for  a  dividing  ovum. 

Always  consider  the  patient's  vegetable  diet  first. 

Bacteria,  &o. 

The  microscope  will  demonstrate  mild  infections  due  to  staphylococci 
from  the  more  dangerous  streptococcal  infections.  Typhoid,  cholera 
and  dysentery  bacilli  can  be  detected  by  culture.  These  are  dealt  with 
under  their  respective  headings.  The  amoebae  can  be  seen  in  fresh 
stools  and  when  the  slide  is  kept  warm  their  movements  can  be  recog- 
nized. Water  kills  them  and  should  not  be  added  in  examining 
them. 

Free  moving   larva?    in    fresh    stools   are    never   ankylostomes    but 
probably  Strongylus  stercoralis. 

Blood. 

Blood  in  small  quantities  and  altered  blood  can  be  recognized  by 
Weber's  test  :  — 

Extract  the  fat  with  ether. 
Rub  the  stool  up  with  water. 

Add  one-third  bulk  of  acetic  acid  and  shake  up  the  whole  Avilh 
ether. 


636 


LABORATORY   HINTS 


a,  Ascaris  hunbricoiJes ;  b,  Trichocephalus  dispar ;  c,  Oxyuris  vermiciilaris  ;  t',  c'^, 
Ankylostomum  diiodenale ;  d,  oncosphere  of  Cestode ;  e,f,g,  xarious  Fasa'o/idir ;  /i,  Schis- 
tosomum  (?)  hainatobiiiin  (from  faeces)  ;  ?,  Schistosovmm  haviatobium  (from  urine). 


THE  EXAMINATION  OE  EJECES  637' 

An  ethereal  solution  of  acid  hiemalin  is  obtained. 
If  altered  blood  is  present  it  is  seen  by  means  of  the  spectro- 
scope, 

THE  DETECTION  OF  OVA. 

This  is  all-import£int.  Their  appearance  is  described  in  the  section 
on  "  Diseases  due  to  Helminths,"  but  to  facilitate  laboratory  work  a 
concise  description  will  be  given  here. 

A  moist  stool  needs  no  water;  to  a  dry  one  add  a  little  water  and 
place  a  small  portion  on  the  slide,  and  press  it  out  gently  with  a  cover 
glass.  As  eggs  are  heavier  than  \\ater  more  will  be  at  the  bottom  of 
a  water  stool. 

Many  eggs  of  Ascaris  matter  little  as  a  rule,  and  those  of  Tricho- 
cephalus  dispar  less,  but  a  few  ankylostomes  are  of  considerable 
importance. 

A  §  objective  should  diagnose  all. 

(i)  Ascaris  lumbricoides. — Ovoid  or  round  with  a  double  contour. 
Thick  clear  yellow  shell.  May  or  may  not  be  surrounded  by 
an  irregular  protective  coat  of  stained  albumin,  granular 
yellow  contents  not  completelv  filling  interior.  The  shell 
resists  formalin. 

(2)  Trichocephalus  dispar. — Small   oval   yellow  eggs,   double  con- 

tour, a  distinct  "  plug  "  of  mucus  at  each  end,  a  granular 
interior  and  a  very  thin  unstained  inner  capsule. 

(3)  Oxyuris  vermicularis. — Xot   unlike   the  ankylostome   ^gg,    but 

somewhat  flattened,  and  contains  a  well-formed  embryo  when 
freshly  passed. 

(4)  Ankylostomum    duodenale. — Unstained,    a    single    thin    trans- 

parent capsule,  segmented  nuclear  matter  into  two  to  forty- 
eight  cells,  does  not  fill  cavity,  an  embryo  in  about  forty-eight 
hours. 

(5)  Trematodes. — These    are    yellow,    small,    and    have    a    lid    or 

operculum,  which  may  be  split  olT.  Their  size  differentiates 
them. 

(6)  Chlonorchis  sinensis. — This  has  a  "  jug  "  shape,  with  a  distinct 

lid  above  and  a  small  spine  below. 

(7)  Schistosoma    haematobium    (from    urine    usually). — Large    ter- 

minal sharp  spike,  thick  shell  containing  embryo.  Add  a 
little  water  to  the  slide  and  the  embryo  will  come  out. 

Schistosoma  mansoni  as  above  with  a  lateral  spine. 

Schistosoma  japonicum  has  a  knob  laterally,  no  spine  and  no 
operculum. 

(8)  Oncosphere    of    Cestode. — A     radical     striation    of    the    thick 

capsule  with  three  pairs  of  booklets  in  the  central  embryonic 
matter  readily  distinguishable  from   other  ova. 


638 


LABORATORY   HINTS 


(9)  Bothriocephalus. — The  only  egg  outside  the  trematode  eggs 
with  a  lid.  Oval,  cellular  contents,  but  little  stained,  other- 
wise much  as  trematode  eggs.  Later  it  becomes  encysted,  and 
ciliated  for  swimming  about  in  water. 

THE   DISSECTION   OF   MOSQUITOES. 

To  kill  the  mosquito,  if  alive,  put  it  in  a  test-tube  and  tap  the  tube 
on  your  arm. 

Remove  legs,  mount  and  dry,  fixing  cover  slip  with  gummed  paper 
having  a  window  in  it.     Study  well  the  complete  structure. 


buccal  cavity 


pharynx 


dorsal  reservoirs 


oesoph.  valve 
and  caeca 


midgut 
begins 


stomach  . 
malpiqhisn  tube    - 

midgut  ends  -  - 
ileum  -  - 

colon 
rectum 


Internal  anatomy  of  the  mosquito 


THE    EXAMINATION    OE    WATER 


639 


Remove  wings  at  right  angles  to  the  body  and  mount  likewise. 

Transfix  the  thorax  with  a  fine  needle  and  remove  the  head  by  pull- 
ing it  away  from  and  backwards  off  the  thorax;  in  this  way  the  salivary 
glands  may  be  withdrawn  from  the  thorax,  and  they  can  be  examined 
under  the  microscope  for  parasites. 

Then  take  the  remainder,  bruise  the  abdomen  across  the  last  seg- 
ment, and  draw  it  away  with  another  needle;  in  this  way  the  internal 
viscera  will  be  dra^^■n  out  also,  and  if  one  is  fortunate  the  salivary 
glands,   if  not  already  removed,  will  be  withdrawn. 

The  stomach,  rectal  glands,  spermathecae,  &c.,  will  be  well  shown. 

Examine  the  gastric  contents  for  malarial  parasites. 

If  the  salivary  glands  are  not  removed,  tease  the  thorax  into  very 
small  portions  in  a  drop  of  saline  and  examine.  There  is  much  debris 
resulting  from  this  method,  and  the  glands  may  be  lost. 


Stomach  of  mosquito  showing  malarial  parasites. 

The  parts  not  being  examined  should  be  kept  in  saline,  or  better, 
liquor  potasscu   in  a  watch-glass. 

Press  the  proboscis  out  under  a  cover  slip  and  examine;  several  of 
the  elements  may  be  seen  in  each  specimen  thus  treated.  Examine 
the  base  of  the  proboscis  and  the  thoracic  muscle  for  filarial  embryos. 


THE  EXAMIXATIOX  OF  WATER. 

Good  waters  are  spring,  deep  well,  and  upland  service  waters. 
Suspicious  waters  are  stored  rain  and  surface  water  from  cultivated 
land. 

Dangerous  waters  are  shallo\\-  well  and  river  water  to  which  sewage 

has  access. 

There  are  four  examinations  :  — 

Biological,   Phvsical,   Bacterial,  Chemical. 


640  LABORATORY    HINTS 

(1)   THE  BIOLOGICAL   EXAMINATION. 

This  enables  us  to  determine  the  absence  or  presence  of  lowly 
organisms,  bacteria,   jDrotozoa,   larvae,  &c. 

The  following  are  common  and  should  be  looked  for  :  — 

In  impure  water  In  sewage 

Vorticella  Rotifera  Carcliesium 

Cienothrix  Ulothiix  Oscillatoria  nigra 

Asterionella  Alg.=e  Leptomitus 

Diatoma  Spirilla  Sphterotikis  natans 

Actinophrys  Spirogyra  Beggiatia 

Protocoeccus  Gammarus  pulex  Ulva  latissinia 

Euglena  Cyclops  Enteromorpha 

Oscillaria  Water  bear  Infusoria 

Desmids  Bomina  longitirastis 

(2)   THE  PHYSICAL   EXAMINATION. 

The  reaction  should  be  neutral. 

Add  a  little  neutral  litmus  to  the  sample. 

COn  will  turn  it  red. 

Remember  that  acid  waters  attack  lead  and  iron  pipes. 

The  colour  should  be  a  pale  blue  or  green. 

Half  till  a  two-feet  tube  and  la}-  it  upon  tlie  table. 

Look  through  the  upper  lialf  which  is  colourless. 

Look  through  the  lower  half  ^\'hich  assumes  the  colour  of  the  water. 

It  should  be  odourless.     To  test  it  warm  to  about  37°  C. 

Certain  mineral  waters  contain  HoS,  also  given  off  by  beggiatoa  and 
crenothrix. 

Volvox  and  uroglena  give  a  fishv  odour. 

Anab^ena  and  rivularia  give  a  grass v  odour. 

Asterionella  and  diatoma  give  an  aromatic  odour. 

There  should  be  no  sediment.  If  there  is  such  it  should  be 
examined  under  the  microscope. 

(3)   THE  BACTERIOLOGICAL  EXAMINATION. 

This   indicates   the   presence   or   absence   of   pathogenic   and    other 
bacteria  and  the  number  thereof.     These  are  :  — 
(i)  Normal   inhabitant  bacteria. 

(2)  Accidental   soil  bacteria. 

(3)  Intestinal  bacteria. 

Sunlight  reduces  their  number  if  the  water  is  shallow  and  the 
exposure  prolonged. 

Cold  inhibits  their  growth  and  warmth  stimulates  it. 

Presence  of  food  materials  stimulates  their  growth. 

Most  bacteria  tend  to  settle  at  the  bottom  and  so  thus  assist  in 
self-purification  of  the  water. 

Typhoid  and  cholera  organisms  die  out  if  stored  long,  about  twelve 
weeks. 


THE    EXAMINATION    OF    WATER  .        641 

To  Collect  the  Sample. 

Use  sterile  glass-stoppered  bottles  and  immerse  in  the  water 
12  in.  below  the  surface  before  removing  the  stopper. 

If  from  a  tap,  let  it  run  for  five  minutes  before  taking  sample. 

Remember  that  a  local  cistern  contamination  gives  a  fallacy  not  to 
be  applied  to  the  water  supply  in  general. 

For  deep  wells  Sclaver's   "smash"   bottles  should   be   used. 

These  are  small  vacuum  bulbs,  let  down  by  a  string  and 
mechanically  broken  when  under  water. 

Examine  the  sample  within  three  hours  or  pack  it  in  ice. 

To  Examine  the  Sample. 

Until  recently  bacteriological  examinations  of  water  supplies  in 
tropical  countries  have  been  few  and  far  between,  owing  to  the  lack 
of  well  equipped  laboratories.  When  sufificient  statistics  are  10  hand 
we  shall  be  able  to  appreciate  the  difference  of  the  bacterial  content  of 
tropical  waters  and  to  modify  existing  standards  of  bacterial  impurity. 

To  one  already  accjuainted  witli  the  subject  in  a  temperate  climate 
there  will  appear  dilficulties  innumerable.  He  will  find  that  standards 
of  impurity  cannot  be  applied  generally  and  that  the  local  water  con- 
ditions vary  enormously. 

For  example  in  the  tropics  :  — 

(i)  The  rains  are  torrential  and  periodic,  so  that  the  bacterial  flora 

of  districts  where  vegetation   is   rank   will  be  brought  down. 

The  surface  organisms  of  sandy  districts,  where  much  vegetation 

is   absent,    mav    give   an    altogether   different    flora    from    the 

above. 

(2)  The  sun  and  soil  kill  off  all  the  H.  coli  communis,  where  it  has 

existed,  but  other  resistant  types  persist,  new  probably  to  the 
sanitary  worker.  Their  significance  as  infectious  and  danger- 
ous agents  in  water  supplies  has  to  be  ascertained. 

(3)  A  clay  subsoil,   instead  of  acting  as  a   lifter  in  purifying  the 

water,  in  some  measure  may  provide  a  culture  media  for  its 
increased  pollution,  oAving  to  the  organisms  being  held  up, 
cultured,  and  swept  away  into  surface  waters  during  the  first 
shower. 

(4)  The  sanitarian  will  be  frequently  called  upon  to  deal  with   the 

bacteria  persisting  after  the  action  of  sun  and  soil,  which 
residual  bacteria  may  not  include  the  notorious  B.  coli  com- 
munis, the  presence  of  which  forms  a  basis  for  a  standard  of 
impuritv  in   temperate  countries. 

(5)  Animals  residing  in  a  catchment  area  will  give  a  very  distinct 

bacterial  flora  from  that  in  temperate  climates  where  the 
pollution  is  largelv  from  human  fcccal  bacteria  from  the  large 
towns  on  the  river  banks. 


642         .  LABORATORY    HINTS 

(6)  The  bacterial  flora  of  human  origin  is  very  different  to  that  of 

animal  origin  and  reasoning  based  upon  the  formisr  and 
applied  to  the  latter  in  tropical  climates  may  often  lead  one 
into  very  serious  error. 

(7)  The  worker  will  find  that  high  winds  laden  with  dust  will  gain 

access  to  his  plates  and  colonies  and  repeatedly  ruin  his  works. 
Each  district  water  supply  must  be  judged  on   its  merits. 
Data  from  many  different   parts  of  the  tropics  must   be   provided 
before    standards    of    impurity    can    be    generally    recommended    and 
adopted. 

The  first  data  came  from  :  — 
Daniels  in  Malay. 

Balfour  and  Archibald  in  the  Soudan. 
Clemesha   in    India. 

(A)  Daniels  working  in  the  Federated  Malay  States  (1908)  proposes 
the  following  as  a  basis  :  — 

(i)  The  number  of  organisms  (exclusive  of  known,  easily  recog- 
nized, non-pathogenic  organisms,  e.g.,  B.  subtilis,  B. 
megaterium,  B.  violaceus,  and  some  of  the  organisms  which 
form  characteristic  yellow  colonies)  which  have  been  proved 
to  be  non-pathogenic  to  lower  animals, 

(2)  The  amount  of  the  water  required  to  react,   forming  acid  and 

gas,  with  MacConkey's  medium,  from  o'2  to  2  c.c.  being 
employed  in  the  tests. 

(3)  Indol    formation    in    forty-eight    hours    in    peptone    water    with 

10  c.c,  5  c.c.  and  i  c.c.  of  the  water  to  be  tested. 
As  a  standard   Daniels  and  Finlayson  suggest  that  :  — 
(i)  Not  more  than    100  organisms,    exclusive  of  those   mentioned, 

should  be  present  in  i  c.c.  of  the  water. 

(2)  That   no  acid  and  gas  should  be  formed  in  twenty-four  hours 

in  MacConkey's  medium  at  37°  C.  with  2  c.c.  of  the  water. 

(3)  That  no  indol  should  be  formed  in  peptone  water  in  forty-eight 

hours  with  5  c.c.  of  the  water  added. 

They  remark  that  the  standard  is  not  a  high  one  but  it  is  exceptional 
to  find  a  natural  water  that  will  pass  all  three  tests. 

In  unprotected  shallow  wells  liable  to  be  polluted  bv  surface  wash- 
ings, they  found  the  average  bacterial  count  to  vary  between  300  to 
900  per  c.c,  while  in  twenty-three  out  of  twentv-seven  wells  examined, 
acid  and  gas  forming  organisms  were  present  in  3  c.c.  and  usually  in 
4  c.c.  of  the  water,  and  indol  formers  in  5  c.c.  in  the  case  of  ten  of  the 
wells.  B.  pyocaneus  was  found  in  one  instance,  and  in  two  cases 
organisms  indistinguishable  from  B.  coli  communis. 

(B)  Balfour  and  Archibald  have  done  good  work  in  the  Soudan 
in  connection  with  river  and  shallow  well  water  in  Khartoum. 


THE    EXAMINATION    OT    WATER  643 

Dealing  with  river  water,  B.  coli  was  found  present  in  o'5  to  i  cc. 
of  the  water  taken  near  the  bank  but  only  in  5  cc.  taken  from  mid- 
stream. 

In  shallow  well  water  B.  pyocyaneus  was  found  and  dysentery  was 
observed  to  follow  the  use  of  this  water. 

Deep  well  water  was  examined  by  Captain  Archibald  with  the 
following  results  :  — 

(i)  The  colony  count  in  i  cc. 
This  was  always  carried  out  with  agar  plates  as  the  heat  prevented 
the  use  of  gelatin.  The  percentages  of  the  various  constituents  of  the 
agar  was  the  same  throughout  all  the  tests.  The  acidity  was  plus  10 
to  phenol-phthalein.  One  cc,  o'5  cc,  and  02  cc  of  the  water 
sample  is  taken  and  run  into  melted  agar  at  a  temperature  of  41°  C. 
This  was  then  placed  out  in  Petri  dishes,  incubated  at  37°  C.  for 
forty-eight  hours,  and  all  colonies  visible  to  the  unaided  eye  counted. 

(2)  Sporogenes  Test. 

Twenty  cc  of  the  sample  of  water  are  pui  into  sterile  milk  con- 
tained in  tubes.  The  milk  is  then  heated  up  to  80°  C.  for  twenty 
minutes,  and  a  laxer  of  hot  vaseline  is  run  on  to  the  surface  of  the  milk 
so  as  to  render  the  latter  anaerobic.  The  milk  tubes  are  then  incubated 
at  37°  C.  for  forty-eight  hours. 

Evidence  of  the  presence  of  the  spores  of  B.  enteritidis  sporogenes 
is  shown  by  the  clotting  of  the  milk. 

(3)   The  test  for  the  presence  of  the  lactose-fermenting  organisms 

and  their  subsequent  isolation. 

Lactose  bile-salt-neutral-red-broth  is  used  and,  as  varying  quantities 
of  \vater  are  inoculated  into  tubes  containing  this  medium,  the  latter 
is  made  up  in  single,  double,  and  triple  strength. 

One  tube  is  inoculated  with  20  cc  of  the  water,  two  tubes  with 
10  cc,  four  tubes  with  5  cc,  five  tubes  with  i  cc,  and  five  tubes  with 
o'oi  cc  All  are  incubated  at  37°  C,  only  tubes  that  give  both  acid 
and  gas  being  counted  as  having  given  the  reaction. 

If  only  one  tube  in  the  first  seven  of  these  gives  a  reaction,  then 
faecal  bacilli  are  present  in  60  cc,  and  if  three  out  of  the  five  i  cc 
tubes  gives  a  positive  reaction,  then  fascal  bacilli  are  considered  to 
be  present  in  i  cc  The  same  applies,  more  or  less,  to  the  o'l  cc 
and  the  o'oi  cc  groups.  The  next  step  in  the  procedure  is  to  isolate 
the  various  f^cal  organisms  present;  and  in  order  to  do  this  satis- 
factorily, the  tube  containing  10  cc  of  water  or  more,  that  has  given 
a  positive  reaction  in  forty-eight  hours,  is  taken.  Of  this,  three  to  five 
platinum  loopfuls  are  removed  and  inoculated  into  10  cc  of  sterile 
water.     The  latter  is  then  vigorously  shaken,  and  one  loopful  of  this 


644  LABORArORV    HINTS 

mixiure  is  then  plated  out  on  lactose  bile-salt-neutral-red  agar,  which 
is  incubated  at  37°  C.  for  forly-eight  hours. 

At  the  end  of  that  time  fifteen  to  twenty  colonies  are  found  to  be 
present  on  the  plate.  Two  colonies  are  in  any  case  picked  off,  and  eacii 
single  colony  is  inoculated  into  a  tube  containing  a  few  drops  of  sterile 
water.  From  these  tubes  further  inoculations  are  made  into  broth, 
glucose-peptone,  and  four  different  special  sugars  are  incubated  at 
37°  C.  The  inoculated  broth  ttibe  is  examined  at  the  end  of  eighteen 
hours  for  motility  and  the  production  of  indol. 

The  glucose-peptone  is  inoculated  for  forty-eight  hours  and  at  the 
end  of  that  time,  if  a  strong  growth  is  present,  a  few  drops  of  a  very 
concentrated  solution  of  caustic  potash  are  added  for  the  purpose  of 
finding  if  the  \^oges-Proskauer  reaction  is  given.  If  this  is  present 
a  bright  ^range-red  colour  is  produced.  It  may  take  twenty- 
four  hours  before  this  colour  is  apparent.  The  four  sugars  that  are 
inoculated  are  saccharose,   sulcite,  adonit  and  inulin. 

In  these  a  positive  reaction  is  represented  at  the  end  of  forty-eight 
hours'  incubation  at  37°  C\  by  the  production  of  acid  and  gas.  It  was 
assumed  that  the  same  species  of  bacillus  ahvays  fermented  the  same 
sugar.  In  connection  with  the  indol  test  the  paradimethyl  benzol- 
dehyde  reaction  was  alwa'ys  used,  as  it  seems  to  be  a  very  delicate  and 
reliable  test.  With  regard  to  the  \\)ges-Proskauer  reaction  consider- 
able difference  of  opinion  exists,  but  there  can  be  but  little  doubt  that 
it  appears  a  good  test  for  the  B.  cloacae,  B.  lactis  aerogenes,  and 
Oxytocus  perniciosus  group. 

The  term  B.  coli  was  only  applied  to  Escherich's  organisms. 

Experiment  (i). 

Sample  taken  from  the  Blue  Nile,  two  metres  from  the  bank. 

Local  rainfall  nil.     River  steadilv  rising  for  three  weeks. 

Temperature  of  water,  27°  C. 

Total  colonies  on  agar  al  37°  C.  were  218  per  c.c. 

F'iecal  bacilli  present  in  01  c.c. 

Sporogenes  test  plus  in  20  c.c. 

Experiment  (2). 

Sample  from  same  place.  Local  rainfall  nil.  River  steadilv  rising 
for  two  months.     Temperature  of  water,  24*5°  C. 

Total  colon}-  count  in  agar  at  37°  C.  was  700  per  c.c. 

Faecal  bacilli  present  in  o"i  per  c.c. 

Sporogenes  test  plus  in  20  c.c. 

Experiment  (3). 

vSample  from  shallow  well  sittialed  in  a  native  vard  about  a  quarter 
of  a  mile  from  the  Blue  Xile. 

The  water  was  at  a  depth  of  19  metres  from  the  surface. 

The  water  temperature  was  30°  C. 


THE    EXAMIA'ATION    Of    WATER  645 

Total  colony  count  in  agar  at  37°  C\  \\as  700  per  c.c. 
Fsecal  bacilli  present  in  o'oi   c.c. 
Sporogenes  milk  lest  plus  in  20  c.c. 

Experiment  (4). 

Sample  from  well  Xo.  7  of  the  Khartoum  water  supply. 
Gas    was   present    in    MacConkex's   medium   when    the    latter    was 
inoculated  with  50  c.c.  of  the  sample. 

Sporogenes  milk  test  negative  in  20  c.c. 

Remarks  on   these  and  other  Tests. 

The  observations  have  been  too  few  to  justify  any  definite  con- 
clusions being  arrived  at  with  regard  to  the  position  that  the  B.  coli 
occupies  in  this  country  as  an  indication  of  recent  pollution. 

Experiments  should  be  carried  out  every  month  of  the  vear  to 
determine  the  effects  of  external  natural  forces,  such  as  sunshine  and 
rain  on  all  organisms  of  faecal  origin. 

There  was  more  faecal  pollution  present  in  a  "  falling  "  than  in  a 
"rising"  river,  although  the  colony  count  in  the  latter  was  nearly 
four  tinies  as  great  as  in  the  former. 

Experiments  have  demonstrated  that  there  are  different  types  of 
lactose  fermenters  present  in  human  freces  in  different  months  of  the 
year. 

Experiments  also  go  to  prove  that  B.  coli  communis  is  extremely 
susceptible  to  the  bactericidal  eft'ects  of  sunlight,  and  that  B.  cosco- 
roba,  I?,  schaefferi,  B.  neapolitanus,  and  B.  vesiculosis  are  extremely 
resistant. 

B.  coli  were  not  found  in  trenches  seven  days  old,  hence  soil 
destroys  them. 

The  chief  bacilli  found  in  the  faeces  of  animals  were  :  — 

B.  coli,  B.  clcaccC,  B.  neapolitanus  and  others  in  goat  fceces. 

B.  schaeft"eri  and   B.  neapolitanus  in  cow  faeces. 

(C)  Probably  the  best  methods  and  the  best  data  yet  given  come 
from   Major  Clemesha  of  the  Madras  Presidency. 

He  states  that  there  must  be  considerable  doubt  as  to  whether  the 
standards  of  purity  in  common  use  amongst  sanitarians  in  England 
were  suitable  to  India. 

Most  Indian  waters  are  loaded  with  fa?cal  contamination  that  no 
analyst  in  England  would  dream  of  passing  as  fit  for  human  con- 
sumption. And  yet  it  is  remarkable  that  the  evil  effects  of  using  such 
water  as  drinking-water  are  not  al\va\s  apparent. 

The  resulting  diseases  are  not  in  proportion  to  the  cause  at  all  times. 

In  England  a  cautious  Medical  Ofificer  would  condemn  water  for 
drinking  which  contained  true  coli  in   i  c.c,  but  in  India  the  B.  coli 


646  LABORATORY    HINTS 

communis  is  a  very  rare  organism  in  its  waters,  while  other  organisms 
are  particularly  common. 

Clemesha  comes  to  these  conclusions  :  :  — 

(i)  That  standards  in  use  in  cold  climates  are  useless,  and  worse 
than  useless,   in  tropical  climates. 

(2)  That  il  is  necessary  lu  separate  the  individual  species  of  bacilli 

by  well-established  tests  and  to  study  their  characteristics  and 
their  position  in   nature. 

(3)  That  it  is  advisable  to  classify  all  lactose  fermenting  organisms 

according  to  their  ability  to  resist  the  action  of  sunlight,  and 
on  this  to  base  the  standard  of  bacterial  purity. 
The  general  conclusions  of  his  experiments  are  :  — 

The  Bacteriology  of  Earth. 

(i)  B.  cloacae,  B.  grunthal,  B.  Xcn  75,  and  to  a  less  extent  B. 
coscoroba,  are  capable  under  favourable  conditions  of  remain- 
ing alive  in  the  soil  for  a  considerable  length  of  time,  probably 
up  to  three  to  four  years. 

(2)  Faical  organisms  of  an}-  kind  do  not  appear  to  exist  in  large 

numbers  after  they  have  been  in  the  earth  for  longer  than 
one  to  two  years;  night  soil  buried  in  the  ground,  even  in 
large  quantities,  loses  most  of  its  organisms  in  this  period. 

(3)  Sporogenes  enteritidis  spores  are  capable  of  remaining  alive  in 

the  ground  for  a  period  of  something  between  three  to  four 
years. 

(4)  B.  coli  communis  has  never  been   isolated  from  the  trenching 

ground  samples,  hence  it  is  j^robable,  though  not  certain, 
that  this  organism  does  not  remain  alive  in  the  ground  as 
long  as  the  more  resistant  organisms  like  cloacae,  &c.  It  has 
been  proved  in  one  experiment  to  exist  in  the  ground  for  a 
period  of  ninel}'-seven  days. 

The  Bacteriology  of  ]]'ater  and  Fccccs  during  Monsoon  Weather. 

(i)  The  conditions  obtaining  during  a  heavy  monsoon  when  fresli 
faeces  mav  find  their  way  easily  into  water,  the  whole  country 
being  submerged,  is  in  some  ^\ay  connected  wiih  the  appear- 
ance of  a  set  of  rare  micro-organisms  in  all  the  water  supplies 
over  a  wide  area.  This  fact  has  not  been  noticed  with 
previcHis  and  subsequent  heavy  rain. 

(2)  These  and  allied  bacteria  may  suddenly  become  extremely 
common  in  the  faices  of  animrds  and  man.  The  cause  of  this 
increased  prevalence  is  unknown. 


THE    EXAMINATION    OF    WATER  647 

(3)  The  flood  conditions  having  passed  away,  the  bacilli  very 
rapidly  disappear  from  all  waters.  Consequently  this 
supports  the  suggestion  that  these  organisms  are  especially 
susceptible  to  natural  forces  inimical  to  bacteria. 

The  Bacteriology  of  Water  from  a  Shallow   Well. 

(i)  In  common  with  most  other  water  supplies,  including  rivers, 
lakes,  springs,  &c.,  B.  cloaca  would  appear  to  be  the  pre- 
dominating organism   in  a  well  after  prolonged  drought. 

(2)  Even  a  small  downpour  of  rain,  after  a  prolonged  spell  of  dry 

weather,  has  a  very  marked  influence  in  increasing  the 
number  of  fascal  bacilli  in  wells  situated  in  porous  soils. 

(3)  Early    showers,    following   on    a    long   period    of    hot    weather, 

have  caused  an  increase  in  the  number  of  Coli  communis  in 
this  well.  It  is  not  by  any  means  certain  where  these  coli 
come  from,  but  it  is  unlikely  that  they  come  from  the  surface 
of  the  ground,  and  probable  that  they  remained  alive  in  (he 
lower  layers  of  the  soil, 

(4)  After  heavy  downpours  of  rain,   in  consequence  of  which  it  is 

certain  that  surface  contamination  has  penetrated  deep  into 
the  layers  of  the  soil,  a  mixture  of  fjecal  organisms  is  usually 
found  in  the  water  obtained  from  wells.  Coli  communis 
appears  to  be  present  after  early  rains,  but  disappears  as  the 
rains  become  more  plentiful. 

(5)  Plentiful   rains  improve  the  quality  of  the  subsoil   water  after 

the  contaminated  surface  water  has  run  off"  the  land. 

(6)  Shallow  wells  are  a  most  unsatisfactory  source  of  water  supply, 

especially  if  they  are  situated  in  a  highly  porous  soil,  and 
unless  the  greatest  possible  care  is  exercised  in  protecting  a 
large  space  of  ground  in  the  immediate  vicinity  from  all 
chances  of  pollution. 

The  Bacteriology  of  Hitman  and  Animal  Fceces. 

(i)  The  flora  of  the  intestinal  tract  of  men  and  animals  are  subject 
to  very  considerable  changes  due  to  influences  which  are  at 
present  unknown.  These  influences  have  been  proved  to 
operate  over  very  wide  areas. 

(2)  Within   certain  very  wide  limits,   these  forces  appear  to  affect 

man  and  animals  equally,  both  as  regards  number  and  kind 
of  micro-organisms. 

(3)  Under    well-defined    conditions,    such    as    heavy    rainfall,    the 

water  supplies  contain  the  same  organisms  as  the  fasces  of 
man  and  animals  at  that  particular  time,  but  this  similarity 
of  bacterial  flora  is  also  noted  occasionallv  when  rain  is 
absent,  and  there  is  no  apparent  cause  for  it.  The  explana- 
tion of  this  occurrence  is  at  present  unknown. 
41 


648  LABORATORY    HINTS 

(4)  Having  regard   to  the  variation    in   tiie  bacteria   in   fceces,   botli 

in  quantitv  and  kind,  no  constant  approximate  composition 
can  be  arrived  at.  Even  in  the  large  groups,  suggested  by 
]\IacConkey,  variation  in  percentage  composition  in  the  same 
animal   is  considerable. 

(5)  Xo   lactose-fermenting  organism   has  been   isolated  by  us  that 

has  been  proved  to  be  the  inhabitant  of  the  intestinal  tract  of 
cattle  or  man  only. 

(6)  The    numerical    relation    of    the    organisms    constituting    Mac- 

Conkey's  groups  in  the  intestines  of  cattle  in  India  is  entirely 
dififerent  from  that  in  England,  while  in  the  intestines  of  man 
it  appears  to  be  very  similar  in  the  two  countries. 

(7)  A  study  of  the  organisms  present  in  faeces  at  different  times  of 

the  year  is  necessary  for  the  proper  interpretation  of  the 
results  obtained  from  water  analyses. 

The  Bacteriology  of  Lake   Water. 

(i)  The  action  of  the  sun  is  powerful  in  destroying  all  faecal 
organisms  in  water,  particularly  where  they  are  "  naked  " 
and  not  surrounded  by  mucus  derived  from  the  intestine. 

(2)  All  f^cal  organisms  do  not  possess  the  power  of  resisting  the 

action  of  sunlight  to  an  equal  degree. 

(3)  It    is    possible    to    divide   f^cal    organisms,    with    a    reasonable 

degree  of  accuracy,  into  the  following  classes  :  — 

(a)  The  delicate  organisms  or  those  that  are  very  susceptible  to 

the  action  of  sunlight. 

(b)  An    intermediate  class   containing  a  very   large   number  of 

organisms  which  occupy  an  intermediate  position  between 
the  two  extremes,  and 

(c)  The   resistant   organisms  or   those   capable   of   resisting  the 

sunlight  for  a  considerable  length  of  time. 

(4)  The  surface  layers  of  any  large  volume  of  water  are  in  conse- 

quence purer  than  the  deeper  ones. 

(5)  Consequently  the  outlet  from  the  reservoir  should  be  arranged 

as  near  the  surface  as  possible. 

(6)  In  the  Red  Hills  lake,  B.  cloacae  is  by  far  the  commonest  faecal 

organism  isolated  from  the  bottom. 

(7)  Coli   communis  even   in   large   numbers,    in  a  huge  volume  of 

water,  disappears  with  great  rapidil\'.  The  organisms  never 
survived  longer  than  six  days. 

(8)  There  is  some  evidence  that  the  middle  layers  of  water  in  the 

lake  of  over  12  ft.  deep  contain  more  water  organisms  and 
more  faecal  bacilli  than  the  bottom  or  the  surface.  When 
taking  samples  the  depth  should  be  stated  from  which  they 
are  taken. 


THE    EXAMINATION    OF    WATER  649 

(9)  The  B.  cloacae  and  B.  grunthal  will  persist  in  water  exposed  to 
the  action  of  sun  and  storage  for  many  months,  and  may 
therefore  be  looked  upon  as  resistant  to  these  forces. 

(10)  The    rareness    (^)f    su(~h    organisms    as    CoH    communis    in    the 

samples  analysed  demonstrates  the  fact  that  organisms  very 
susceptible  to  the  action  to  sunlight  do  exist,  Coli  communis 
being  the  commonest  of  these. 

(11)  Storage   in   the   tropics   is  capable  of   rendering  a  highly  con- 

taminated water  exlremelv  pure,  and  of  killing  a  large  number 
of  the  faecal  organisms  present  after  gross  pollution. 

In  estahlishlui^  bacterial  standards,  for  drinking-water  in  India,  a 
preliminary  grouping  is  given  to  us  thus  :  — 

Class  (i). — See  (3),  (a)  above. 

Those  Avaters  containing  Coli  communis  and  the  members  of  the 
susceptible   group. 

The  contamination  is  recent  and  dangerous. 

These  are  not  commonly  found. 

Class  (2). — See  (3),  (c)  above. 

Those  Avaters  containing  such  resistant  organisms  as  B.  grunthal, 
or  B.  cloaca?  or  both. 

These  represent  a  pollution  months  old  from  a  water  supply  becom- 
ing exhausted. 

Class  (3). 

Those  waters  containing  both  the  above  organisms. 

This  condition  is  to  be  expected  in  rainy  weather  and  flooded  rivers. 

In  general  be  guided  by  :  — 

The  number  of  faecal  organisms  present. 

The  number  of  different  species  present  in  the  ten  colonies  isolated. 

To  which  group  the  organisms  tend  to  belong  most. 

In  fresh  samples  of  fa?cal  contamination  the  Lactis  aerogenes  is  not 
often  present,  hence  if  it  is  found  it  may  be  considered  as  evidence  that 
a  considerable  amount  of  purification  of  the  water  has  taken  place. 

Clemesha  proposes  to  classify  river  waters  thus: — 
(i)  Good  river  water. 

This  should   not   contain    more    than    100   colonies   on   a  (jar   at 

o 

Ftecal  organisms  should  not  exceed  one  in  10  c.c. 
No  organisms  in  Class  (i)  should  be  present  in  50  c.c. 
Ffecal  organisms  present  should  belong  to  either  Class  (3)  or 
the  more  resistant  group  of  Class  (2). 
(2)  Fair  or  usable  river  water. 

This  should   not   contain    more   than   300   colonies   on    agar   at 


o 


7°  C. 


650  LABORATORY    HINTS 

It  should  not  contain  more  fc'ecal  organisms  than  one  in  i  c.c. 
There  should  not  be  any  organisms  of  Class  (i)   in   less  than 

29  c.c. 
The  fecal  organisms  present  should  consist  mainly  of  mixtures 

of  Class  (3)  and  Class  (2),  and  there  should  be  a  tendency  for 

one  organism  to  preponderate. 
(3)  Bad  river  waters  to  be  condemned. 

When  the  total  colonies  are  more  than  800  on  agar  at  37°  C. 
When   lactose  fermenters  are  present   in  number  of    10   to    100 

per  c.c. 
When  organisms  belonging  to  Class  (i)  exceed  one  in  5  c.c. 
When  the  faecal  organisms  isolated  (Class  (i)  being  absent)  are 

rich  in  varieties  such  as  occur  in  an  emulsion  of  faeces. 

For  Well  and  Spring  ]]\iters. 

A  good  water  should  contain  no  f^cal  bacilli  in  20  c.c. 

No  Class  (i)  in  100  c.c. 

Total  colonies  under  i^ft^'  per  c.c. 

For  the  details  of  this  excellent  ^^'ork  one  must  see  "A  Study  of 
the  Bacteriology  of  Drinking  Water  Supplies  in  Tropical  Climates'* 
(1909),  by  W.  W.  Clemesha. 

Sanitarians  are  recommended  to  adopt  similar  methods. 

Unfortunately  he  has  not  told  us  anything  of  deep  wells. 

It  seems  to  be  agreed  that  if  experiments  are  carried  out  along  the 
lines  adopted  by  Clemesha,  in  most  tropical  countries,  sufificient  data 
will  be  available  for  suggesting  some  standard  for  a  tropical  water 
supply  fit  for  drinking  purposes. 

We  venture  to  give,  however,  for  comparison,  the  standards  as 
adopted  by  British  sanitarians. 

(a)  Enumerate  the  bacteria  capable  of  growth  at  room  temperature 

(18-22°  C). 

(b)  Identify  and  enumerate  the  bacilli  coli  present. 

(c)  Enumerate  bacteria  capable  of  growth  at  blood  heat  (36°  to 
38°  C). 

(d)  Enumerate  the  streptococci  present. 

(e)  Detect  the  typhoid  bacillus. 
(/)  Detect  the  cholera  vibrio. 

(a)  To  enumerate  bacteria  grown  at  room  temperature. 

Nutrient  gelatin  is  most  often  the  medium  used. 

(In  countries  with  a  high  temperature  nutrient  agar  should  be  used, 
but  it  is  not  as  useful  as  nutrient  gelatin  in  showing  the  presence  of 
liquefying  organisms  (Simpson).) 

Professor  Hewlett  prefers  beef  broth. 

The  percentage  of  gelatin  should  be  increased  with  the  temperature. 


THE    EXAMINATION    OF    WATER  651 

]\Ielt  the  gelatin  in  three  tubes  in  a  water  bath  or  incubator  at 
blood  heat. 

Inoculate  three  sterile  Petri  dishes  with  0*5,  o'3,  0*2  c.c.  of  water 
well  shaken. 

Pour  the  contents  of  a  gelatin  tube  into  each  Petri  dish. 

]\Iove  quietly  to  mix  the  water  and  gelatin. 

Allow  to  solidify  on  a  flat  surface. 

Count  the  colonies  at  the  end  of  seventy-two  hours,  but  inspect 
daily. 

1,000  organisms  can  be  counted  on  a  10  cm.  dish,  but  200  colonies 
should  be  the  maximum. 

In  pure  water  less  than  10  per  cent,  will  liquefy  gelatin. 

In  the  purest  upland  streams  i  c.c.  contains  often  under  100 
bacteria,  while  in  town  sewage  the  same  quantity  contains  millions. 

In  deep  well  water  over  100  organisms  per  c.c.  is  conclusive 
evidence  of  contamination.  500  per  c.c.  and  above  is  suspicious  water, 
1,000  or  more  means  condemnation  of  the  water  for  drinking  purposes. 

(b)  To  enumerate  bacteria  grown  at  blood  heat. 

Inoculate  two  sterile  Petri  dishes  with  i  and  o'l  c.c.  of  the  sample. 
Melt  two  tubes  of  nutrient  agar  and  allow  to  cool  to  45°  or  40°  C. 
and  pour  into  the  dishes.     Mix  quickly  and  place  to  cool. 
Count  them  at  the  end  of  forty-eight  hours. 

(c)  To  enumerate  Bacillus  coli  present.  The  most  important  datum 
of  bacterial  examination. 

The  sample  should  be  50  c.c.  of  shallow  well  and  surface  water. 

The  sample  should  be  100  c.c.  of  deep  well  water. 

Add  a  medium  that  contains  a  substance  fermented  by  the  Bacillus 
coli,  and  also  a  substance  to  inhibit  the  growth  of  other  water 
organisms  as  Pake's  method,   glucose-formate  broth. 

Savage's  method,  neutral  red  glucose  broth. 

MacConkey's  method,   bile-salt  broth,   generally  used. 

In  this  is  lactose,  the  Bacillus  coli  ferments  giving  acid  gas. 

Sodium  taurocholate...         ...         ...         ...  o"5  per  cent. 

Wittes'  peptone  ...         ...         ...         ...  2*0         „ 

Lactose  ...         ...         ...         ...         ...  ro         „ 

Agar 2-0        „ 

Made  with  tap  water  and  i  per  cent,  solution  of  neutral  red  added. 
A  double  strength  is  also  made. 

Bacillus  coli  gives  bright  red  colonies,  and  Bacillus  typhosus  white 
colonies  without  fermentation. 

Inoculate  four  tubes  containing  5,  10,  15,  20  c.c.  of  this  double 
strength  medium  with  5,   10,  15,  20  c.c.  of  the  water  sample. 

Incubate  at  42°  C.  for  twenty-four  to  forty-eight  hours. 


652  LABORATORY    HINTS 

If  acid  and  gas  is  produced  it  is  presumptive  evidence  of  Bacillus 
coli. 

Take  a  loopful  of  liquid  from  the  tube  with  the  smallest  amount  of 
water,  and  add  it  to  a  test-tube  of  10  c.c.  of  sterile  water.  Shake  and 
inoculate  a  similar  tube  \\\{\\  one  loopful  of  this. 

Repeat  from  the  second  to  a  third  tube. 

Smear  one  loopful  of  each  dilution  over  a  gelatin  or  agar  slope. 

One  of  these  is  sure  to  give  discrete  colonies. 

Subculture  these  into  tubes  of  nutrient  broth,  and  later  examine  for 
motile  organisms  and  do  a  Gram  stain. 

From  the  broth,  culture  inoculations  are  made  into  the  various 
media  necessary  to  identify  the  organism  and  the  attributes  of  the 
organism  thus  collected. 

If  typical  Bacillus  coli  have  been  found  in  the  tube  to  which  10  c.c 
of  the  w^ater  had  been  added  and  not  in  that  of  5  c.c,  it  would  be  stated 
that  Bacillus  coli  was  present  in  10  c.c,  but  absent  in  5  c.c. 

Those  waters  showing  no  Bacillus  coli  in  50  c.c.  are  of  a  high 
degree  of  purity. 

Spring  waters  should  not  show  them  in  50  c.c 

In  upland  surface  waters  their  presence  in  10  or  40  c.c.  means 
contamination,  but  not  necessarily  dangerous,  as  it  may  be  from 
animals  grazing,  and  not  pathogenic  human  excreta. 

If  there  are  more  Bacillus  coli  than  500  per  litre  the  water  is 
suspicious. 

{d)  To  enumerate  streptococci. 

As  above,  but  use  glucose  broth  or  glucose  neutral  red  broth,  and 
incubate  at  37°  C.  for  four  hours,  and  then  make  a  hanging  drop 
preparation. 

The  primary  Bacillus  coli  tubes  can,  of  course,  be  examined  for 
them. 

Streptococci  do  not  multiply  after  sampling,  but  Bacillus  coli  do. 

Their  numbers  should  not  exceed  that  permissible  for  Bacillus  coli. 

{e)  To  detect  the  typhoid  bacillus. 

This  is  difficult.  Remember  that  as  the  incubation  of  typhoid 
fever  is  twelve  to  fourteen  days,  the  organisms  ma}-  have  disappeared 
from  the  water  before  the  examination  is  started.  Water  containing 
typhoid  bacilli  will  contain  large  numbers  of  Bacillus  coli  also.  Other 
organisms  may  overgrow  those  of  the  typhoid  bacilli. 

There  are  many  wavs  of  concentrating  the  agar  in  the  water,  such 
as  filtering  through  a  porcelain  filter,  adding  a  little  alum,  entangling 
them  in  the  aknninium  hvdrate,  centrifuging,  &c. 


THE    EXAMINATION    OE    WATER  653 

To  isolate  the  organism  from  the  concentrated  deposit  :  — 

Plate  in  Conradi-Drigalski  agar  or  litmus  lactose  bile-salt  agar. 

Subculture  the  colonies  into  broth  and  work  out  their  attributes  in 
other  media. 

Try  agglutinating  (Widal)  reactions  in  each  subculture. 

Do  a  Pfeiffer's  test,  depending  upon  bacteriolysis  to  clinch  a 
diagnosis. 

(/)  To  detect  tlic  cholera  vibrio.     (See  "  Cholera.") 

(5)  THE  CHEMICAL  EXAMINATION  OF  WATER   (after  Stewart). 

The  results  of  water  anahses  are  expressed  in  parts  per  100,000  or 
as  grains  per  gallon  =  parts  per  70,000,  since  there  are  70,000  gr.  per 
gallon.  100  c.c.  is  a  convenient  quantity  to  work  with  for  certain 
estimates.  When  one  is  using  standard  solutions  of  a  strength 
I  c.c.  ^=  o'ooi  grm.,  the  number  of  c.c.  used  in  the  titration  gives  the 
result  in  parts  per  100,000.  Likewise,  if  70  c.c.  are  taken  of  the 
sample,  the  actual  titration  gives  the  result  in  grains  per  gallon.  This 
much  facilitates  the  work  as  is  demonstrated  in  a  simple  example 
thus  :  — 

In  estimating  chlorine  in  a  water  sample,  3*4  c.c.  of  standard  silver 
nitrate  solution  (i  c.c.  =  o'ooi  grm.  of  chlorine)  were  required  to  reduce 
it.  Hence  there  were  3*4  parts  of  chlorine  in  100,000  parts  of  the  water 
because  :  — 

3"4  X  o-ooi   X   100,000 

=3"4 

100 

To  convert  grains  per  gallon  to  parts  per  100,000  multiply  the 
result  by  10  and  divide  by  7,  and  conversely  to  multiply  bv  7  and  divide 
by  10  gives  grains  per  gallon. 

One  is  required  to  ascertain  the 

(1)  Total  solids  (6)  Nitrates 

(2)  The  degree  of  hardness  (7)  Oxidizable  organic  matter 

(3)  The  metals  present  (8)  Saline  ammonia 

(4)  Chlorine  (9)  Albuminoid  ammonia 

(5)  Nitrites  (10)  Degree  of  aeration 

in  the  ordinary  drinking-water  and  sewage. 

These  will  be  dealt  with  seriatim,  applied  to  drinking-water  first. 

(1)  To  Estimate  the  Total  Solids. 

Weigh  a  small  porcelain  dish. 
Take  200  c.c.  of  the  water  sample. 

Evaporate  to  dryness  in  dish  over  a  water  bath,  pouring  water  in 
as  it  evaporates  until  200  c.c.  have  been  poured  in. 
Dry  the  dish  in  a  water  oven  for  an  hour. 
Cool,  weigh  the  dish  and  residue. 


654  LABORATORY    HINTS      ' 

Deduct  the  weight  of  dish,  remainder  equals  total  solids  in  200  c.c. 
Simply  calculate  how  much  in  100,000  c.c. 
Example : — 

Dish  +  total  solids  —  27*848  grm. 
Dish  alone  =  27797     ,, 


Weight  of  residue    =    o'05i  grm.  x  100,000 

=  25'5  parts 

200  per  100,000 

(2)  To  Estimate  the  Hardness. 

The  hardness  of  water  is  largely  due  to  the  presence  of  bi- 
carbonates,  sulphates  and  chlorides  of  calcium  and  magnesium. 

(i)  Total  Hardness. 

In  a  stoppered  bottle  of  150  c.c.  capacity  place  100  c.c.  of  sample. 

Run  in  from  a  burette  standard  soap  solution  (i  c.c.  =  o"ooi  grm. 
CaCOg),  shaking  vigorously  until  a  permanent  lather  of  \  in.  is 
obtained. 

Exaynple. 

13*8  c.c.  of  soap  solution  is  required. 

Hence  I3'8   x   cooi  is  contained  in  100  c.c.  of  water. 

I3'8   X   001    X    100,000 
=   I3'8  parts  per   100,000. 

10 

If  100  c.c.  are  used  this  latter  calculation  is  avoided  as  the  c.c.  used, 

i3'8  in  this  case,  indicates  the  parts  per  100,000. 

(2)  Temporary  Hardness. 

This  can  be  removed  by  boiling. 
It  is  due  to  the  bicarbonates  of  lime  and  magnesia. 
On  boiling  the  COo  is  driven  off  and  the  carbonates  are  precipitated. 
Commercially  it  is  removed  by  adding  lime. 

The  degree  of  temporary  hardness  is  calculated  by  subtracting  the 
permanent  from  the  total  hardness. 

(3)  Permanent   Hardness. 

This  is  due  to  the  sulphates  and  chlorides  of  calcium  and 
magnesium. 

They  are  soluble  in  water  and  cannot  be  precipitated  by  boiling. 
To  estimate  them  :  — 

Boil   100  c.c.   in   a  beaker  for  fifteen  minutes. 

Filter  when  cold  and  make  up  the  filtrate  with  distilled  water  to 
100  c.c.     Shake  well. 

Run  in  soap  solution  as  described. 
Example  :  4*2  c.c.  required. 
Hence  4*2  parts  per  100,000. 

But  the  total  hardness  was  138 

=  9'6  parts  per  100,000  temporary  hardness. 

The  permanent     „  „     4-2 


THE    EXAMINATION    OF    WATER  655 

(3)  Detection  and  Estimation  of  Poisonous  Metals. 

To  100  c.c.  of  the  water  add  a  few  drops  of  acetic  acid. 
Pass   in    H2S. 

A  light  clear  brown  deposit  =  copper. 
A  dirty  granular  deposit  =  lead. 
Copper. 

To  another  100  c.c.  add  a  little  acetic  acid. 
To  this  add  2  c.c.  of  fresh  solution  of  potassium  ferrocyanide. 
To  estimate  the  amount  of  copper  present :  — 
Match  this  chestnut  brown  colour  by  a  standard  copper  solution. 
Copper    solution    (i    c.c.  =  o'cooi     grm.    Cu)    as    is    described    in 
Nesslerizing  the  ammonia   solutions. 
Lead. 

To  100  c.c.  of  water  add  a  little  acetic  acid. 
To  this  add  a  few  drops  of  potassium  chromate  and  stir  well. 
A  yellow  turbiditv  (of  lead  chromate)  indicates  lead. 
If  lead  is  in  excess  a  yellow  deposit  will  be  formed. 
Pass  H.S    in  100  c.c.  of  the  sample. 

Match    the    brown    coloration    wilh    a    standard    lead    solution 
(i  c.c.=o"oooi  grm.  Pb)  to  estimate  lead. 
Example,    12  c.c.  of  the  standard  solution  are  necessary  to  match 
the  colour  in  the  given  sample. 

Hence  there  is  o'oooi  x  12  grm.  of  lead  in  the  100  c.c.  of  the  sample, 
there  is  qooqi  x  12  x  ico.o     r-2  grm.  Pb  in  100,000  parts. 

ICO 

Iron. 

If  neither  copper  nor  lead  is  present  test  for  'won. 

Take  100  c.c.  of  the  sample. 

Add  5  c.c.  of  nitric  acid,   i  in  5. 

Then  5  c.c.  of  10  per  cent,  potassium  sulphocyanide. 
A  red  coloration  indicates  iron. 

Match  this  colour  with  a   standard   iron  solution   (i    c.c.  =  o'cooi 
c.c.  grm.  Fe)  to  estimate  the  amount. 

If   the   colour   is   too    intense   to   be    matched   conveniently    take    a 
smaller  amount  and  dilute  to   100  c.c.   with  distilled  water. 

(4)  To  Detect  and  Estimate  Chlorine, 

This  is  present   in   most   waters  as  sodium,   potassium  or  calcium 
chloride. 

Its  presence  may  be  due  tO' : — 

(i)  The   water   passing   through    saline   compounds    in    the   strata, 
e.g.,  sandstone,  greensand. 

(2)  Pollution  bv  organic  matter,  especially  urine. 

(3)  Deep  wells  near  the  sea  coast. 

(4)  Tidal    rivers. 


656  LABORATORY    HINTS 

Place   100  c.c.  of  the  water  in  a  large  porcelain  dish. 
Add  a  few  drops  of  5  per  cent,  potassium  chromate. 
Run  in  from  a  burette  standard  AgXOg  solution  (i  c.c.  =^o"ooi  grm. 
of  CI)  until  a  reddish  tint  remains. 
Silver  chromate  is  formed  which  is  red. 
If  sa}'   r;  c.c.  are  required  then  these  are  the  parts  per   100,000. 
Since  17  x  q-coi  x  -100.000  =    j--, 

lOD 

To  obtain  the  results  in  terms  of  sodium  chloride  multiply  the 
result  by  i'647  since  CI    x    r647  =  NaCl. 

This  factor  is  obtained  from  the  ratio  li^^^i  _  5^   =   i'647- 

t-i         3S-5 
(5)  To  Detect  and  Estimate  Nitrites. 

These  generally  indicate  recent  organic  pollution. 
Nitrites  are  eventually  oxidized  to  nitrates. 

Sometimes  nitrates  are  reduced  to  nitrites  by  ferrous  salts  or  in 
deep  wells  due  to  the  metal  of  the  bore  pipes,  but  these  are  the 
exceptions. 

Nitrites  are  usually  found  in  sewage  effluent. 

Test  (i). 

Place  100  c.c.  of  the  water  in  a  Nessler  cylinder. 

Add  6  drops  of  dilute  HCl. 

Add  6  drops  of  naphthylamine  hydrochloride. 

Add  6  drops  of  sulphanilic  acid. 

Stir  with  a  glass  rod. 

A  pink  colour  indicates  nitrites. 
If  no  coloration  in  fifteen  minutes  nitrites  are  absent. 
Test  (2). 

Place  100  c.c.  of  water  in  a  Nessler  cylinder. 
Add  a  few  drops  of  H2SO4. 
Add  I   crystal  of  KI  and  mix  well. 

Add  5  c.c.  of  fresh  starch  solution.     A  blue  colour  indicates  nitrites. 
Test  (3). 

To  100  c.c.  of  water  add  a  few  drops  of  diluted  HCl. 
Add  5  c.c.  of  metaphenylene-diamine  solution. 
Mix  and  allow  to  stand. 

A  yellowish-orange  colour  indicates  nitrites. 
If  the  reagent   is   not  colourless,   shake   it   with  a   little  animal 
charcoal  and  filter. 
To  estimate   the   amount   match   this   colour   by   using  a   standard 
sodium  nitrite  solution  (i  c.c.  =  o'ooi  grm.). 

(6)  To  Detect  and  Estimate  Nitrates. 

These  are  usually  present. 

Strata  containing   red   sandstone,   &c.,    impart   them   to   the   water. 


THE    EXAMINATION    OE    WATER  657 

They   are  also   the  final   products  of   completely   oxidized   organic 
nitrogenous  matter. 

Test  (i). 

Fill  a  large  test-tube  with  the  sample. 

Add  a  few  c.c.  of  diphenylamine  solution. 

Pour   concentrated    H2SC)4    carefully    down    the    side    of    the    tube. 

A  blue  ring  at  tiie  junction  of  the  two  licfuids  =  nitrates. 

Test  (2) 

Repeat  the  above  using  a  solution  of  brucine  in  H2SO4. 
A  red  ring  is  formed  ^\hicll  turns  yellow,  then  brown. 
Both  these  tests  are  given  ^\ilh  nitrites  also,   hence  nitrites  should 
be  excluded  or  Test  (3)  applied,  which  does  not  react  with  nitrites. 

Test  (3). 

Evaporate  50  c.c.  of  the  water  to  dryness  in  a  water  bath. 

Add   I    c.c.  of  phenolsulphonic  acid. 

]\Iix  well  Avith  a  glass  rod. 

Heat  on  a  water  bath  for  one  minute. 

Transfer  the  fluid  to  a  100  c.c.  Nessler  glass,  washing  the  basin  and 
rod  with  water,  adding  same  to  the  glass. 

Add  10  c.c.  of  concentrated  ammonia. 

Stir  and  make  up  to  100  c.c.  with  distilled  water  and  shake. 

A  yellow  coloration  denotes  nitrates. 

By  this  method  the  nitrates  are  converted   into  picric  acid. 
The  ammonia  forms  ammonium  picrate  which  has  an  intense  yellow 
colour. 

To  Estimate. 

Method  (i). 

Retain  the  above  yellow  fluid  and  match  it. 

Take   5   c.c.   of  the  standard   KXO3   solution   (i    c.c.  =  o"oooi 

grm.  N). 
Evaporate  to  dryness  and  treat  it  exactly  as  the  above  solution. 
There  are   now   two  cylinders   of  yellow   fluid   that   are    not    of 
similar  tints. 

Suppose  the  Sample  is  the  darker  of  the  tzvo  Solutions. 

Pour  out  some  of  the  darker,  say  15  c.c,  and  make  up  the 

85  c.c.  to  100  c.c.  with  distilled  water. 
If  now  too  dark  pour  out  more,  say  10  c.c,  and  make  up  the 

90  c.c.  to  100  c.c  with  distilled  water. 
Suppose  the  tints  now  coincide  we  get  :  — 

looj^oo  X  00005  X  loo.ooo  _  J.       ^^^^  ^  ^^  j^ijj.^^fg       .  100,000. 

85    X    90    X    50  ^'    ^  ^ 


658  LABORATORY   HINTS 

Suppose  the  Water  Sample  is  the  lighter  of  the  two. 

Pour  out  some  of  the  darker,  say  first   15  c.c,  then   10  c.c. 
as  above,  then  the  amount  of  the  orif^inal  solution  remain- 
ing- in  the  standard  cyHnder  is   -  ^  ^  '^° 
°  -^  100  X   1 00 

Therefore  in  the  sample  we  have  :  — 
85  X  90  X  00005  X  100,000 


ICO  X   100  X  50 

Method  (2). 


=  0*766  parts  N  as  nitrate  per  100,000  parts. 


Dissolve  2  grm.  of  sodium  hydrate  in  100  c.c.  of  distilled 
water. 

This  is  a  pure  solution  of  caustic  soda  free  from  nitrates. 

Add  100  c.c.  of  the  sample  water  and  a  piece  of  aluminium  foil. 

Permit  to  stand  for  twenty-four  hours  in  a  dark  place. 

Then  all  the  oxidized  nitrogen  is  converted  into  ammonia. 

Distil  this  solution  and  Nesslerize  as  above. 

Before  distilling  test  for  nitrites  to  see  that  all  have  been  reduced 
to  nitrates. 

Method  (3). 

Coat  some  zinc  foil  with  copper  by  exposing  it  to  copper  sul- 
phate until  it  becomes  black. 

Put  zinc  foil  copper-coated  into  a  bottle  with  250  c.c.  of  the 
sample  water,  add  0*5  grm.  oxalic  acid  and  leave  for  twenty- 
four  hours. 

All  oxidized  nitrogen  is  converted  into  ammonia. 

Distil  and  Nesslerize. 

(7)  To  Estimate   the   Oxidizable  Organic   Matter  in   Water    (Oxygen 
absorbed) . 

This  can  be  done  in  three  hours  at  37°  C,  or  in  four  hours  at  80°  F. 

The  putrescent  organic  matter  is  chiefly  oxidized  in  the  first  thirty 
minutes. 

Oxygen  may  be  absorbed  by  nitrites,  HoS,  ferrous  salts,  &c. 

In  a  stoppered  bottle  of  400  c.c.  capacity  place  200  c.c.  of  sample 
and  add  10  c.c.  of  KMnO^  solution  (i  c.c.  =o"oooi  grm.  of  available 

Add   10  c.c.  of  H2SO4  (i    in  4). 

Place  in  incubation  at  37°  C.  for  three  hours. 

If  the  pink  colour  quickly  fades  add  more  KMnO^  always  counting 
the  c.c.  used. 

At  the  end  of  three  hours  at  37°  C.  a  pink  colour  should  be  present. 

Cool  under  the  tap. 

Add  5  c.c.  of  KI  10  per  cent,  solution. 

Run  in  from  burette  sodium  thiosulphate  solution  (i  grm.  in 
1,000  c.c.)  until  the  yellow  colour  has  nearly  disappeared. 


THE    EXAMINATION    OF    WATER  659 

Add  5  c.c.  of  fresh  starch  solution. 

Add    more    thiosulphate    until    the    blue    colour    has   disappeared, 
shaking  constantly. 

We  will  suppose  that  15*5  c.c.  were  necessary. 

We  must  now  find  out  the  strength  of  the  thiosulphate  in  terms  of 
O,. 

For  this  we  do  a  blank  experiment. 

Fill  a  similar  bottle  to  the  above  with  200  c.c.  of  distilled  water. 

Add  at  once  5  c.c.  of  10  per  cent.  IvI,   10  c.c.  of  HoSO^  (i   in  4) 
and  10  c.c.  of  KMn04  a?  above. 

Run  in  the  thiosulphate  solution  from  the  burette  until  the  yellow 
colour  has  nearly  disappeared. 

Then  add  5  c.c.  of  fresh  starch  solution  and  add  more  thiosulphate 
until  the  blue  colour  has  disappeared. 

Suppose  20'5  c.c.  are  necessary. 

Thus  blank  experiment  requires  20'5  c.c.  of  thiosulphate. 
Water  sample  recjuires   i5"5  c.c.  of  thiosulphate. 
Therefore  the  difiference  is  5  c.c.  of  thiosulphate. 

Now  20"5  c.c.  of  thiosulphate  =  10  c.c.  of  KjMnOi  or  o'ooi  grm.  of 

Hence  5  c.c.  of  thiosulphate  ?:^^^L^iil^=  0-00026  of  O,. 
In  200  parts  of  sample  water  0*00026  parts  of  O,  are  absorbed. 
.".  in  100,000  parts  of  sample  water  o'l^  parts  of  Oo  are  absorbed. 
Water  cannot  be  judged  on  this  experiment  alone  as  peaty  waters 
absorb  much  oxygen   and  they  are  not  as  detrimental  as  waters  ab- 
sorbing the  same  amount  due  to  the  presence  of  nitrites. 
Those  not  exceeding  o'l  =  good  organic  purity. 
Those  not  exceeding  0*3  =-  medium  organic  purity. 
Those  not  exceeding  0*4  =  doubtful  organic  purity. 
Those  more  than  o"4  =  polluted  organic  purity. 
If   other   than    upland   surface   waters   are   examined    use    half   the 
amount  for  the  experiment. 

(8)  To  Estimate  Free  and  Saline  Ammonia. 

During  decomposition  of  organic  matter,  X  combines  with  H  and 
forms  ammonia.  This  may  combine  with  the  saline  constituents  of  the 
water  forming  saline  ammonia  or  remain  free. 

As  this  ammonia — the  product  of  decomposing  animal  matter — is 
verv  small,  all  vessels,  &c.,  used  in  the  experiment  must  be  ammonia 
free. 

Place  300  c.c.  of  distilled  water  into  a  flask  and  distil  it  over. 

Test  the  distillate  with  2  c.c.  of  Nessler's  solution  until  it  does  not 
give  a  yellow  colour.     Then   the  vessel   is  ammonia   free. 

(Nessler's  solution  is  caustic  potash  with  potassio-mercurio  iodide.) 


66o  LABORATORY    HINTS 

In  the  emptied  flask  place  500  c.c.  of  the  water  sample. 

Add  a  pinch  of  calcined  sodium  carbonate. 

The  ammonium  carbonate  thus  formed  yields  ammonia  readily  on 
boiling. 

Distil  and  collect  the  distillate  in  50  c.c.  Nessler's  glasses  suc- 
cessively. 

Add  2  c.c.  of  Nessler's  solution  to  the  first  cylinder,  stir  and  let  it 
stand  three  minutes. 

Match  this  tint  with  a  standard  solution  of  ammonium  chloride 
(i  c.c.  =  o'ooooi  grm.  of  NHg). 

In  a  Nessler's  glass  place  50  c.c.  of  distilled  water. 

Add  2  c.c.  of  Nessler's  solution. 

To  this  add  o'5,  or  i,  or  2  c.c.  of  the  standard  ammonium  chloride 
until  the  tint  is  the  same  as  the  first  cylinder  distilled. 

If  the  tint  does  not  match  make  a  fresh  standard  or  have,  say,  six 
cylinders  containing  known  and  varying  amounts  for  matching. 

Treat  the  other  cylinders  the  same  as  thev  are  distilled  over. 

Two  or  three  are  usually  sufificient  and  contain  all  the  ammonia. 

Thus  the  first  cylinder  recjuires  3*0  c.c.  of  ammonia  chloride  solution. 

And  the  2nd  cylinder  requires  o"8    ,,  ,,  ,, 

And  the  3rd  cylinder  requires  nil. 


>> 


3-8  c.c. 
Hence  amount  of  NH3  in  500  c.c.  of  water  is  3'8xo-ooooi. 
Hence  amount  of  NH3  in  100,000  c.c.  of  water 

3"8  X  O'OOOOI  X  ico,ooo 

=  o'O076 

500 
=  0*0076  parts  per  100,000. 

Save  the  resulting  solution  for  estimating  albuminoid  ammonia. 
Good   water   does    not    usually   contain    more    than   o'oi    parts   per 
100,000. 

(9)  To  Estimate  Albuminoid  Ammonia. 

When  nitrogenous  organic  matter  is  heated  with  an  alkaline 
solution  of  KMnO,,,  it  is  oxidized  and  part  of  the  On  present  is  con- 
verted into  ammonia. 

If  the  albuminoid  ammonia  exceeds  the  saline  ammonia  it  indicates 
vegetable  pollution. 

If  the  saline  ammonia  is  high  and  the  albuminoid  ammonia  above 
0.005  ^vith  high  figures  for  saline  ammonia  it  indicates  animal  pollution. 
There  may  be  free  ammonia  in  deep  well  water,  the  metal  of  the  bore 
pipes  reducing  the  nitrates. 

Boil  in  a  beaker  fifteen  minutes  50  c.c.  of  alkaline  permanganate 
solution  with  100  c.c.  of  water. 


THE  EXAMINATION  OE  WATER  66i 

Pour    iliis    into    the    flask    with    its    contents    left    from    the    above 
experiment. 

Add  a  few  pieces  of  pipe  stem  to  prevent  bumping. 

Distil  over  about  four  50-c.c.  Xessler  glasses. 

Xesslerize  and  estimate  as  for  saline  ammonia. 

The  amount  in  good  water  does  not  exceed  o'oi   part  per  100, oco. 

(10)  To  Estimate  the  Aeration  of  Waters  (O2  dissolved). 

Measure  exactly  the  volume  of  a  stoppered  bottle  about  250  c.c. 

Fill  completely  with  water  sample,  avoiding  air  bubbles. 

By  means  of  a  long  pipette,  the  rod  inserted  close  to  the  bottom  of 
the  bottle  :  — 

Add  I  c.c.  of  40  per  cent,  manganese  chloride. 

Add  3  c.c.  of  (50  per  cent  NaOH  and  10  per  cent.  KI)  solution. 

Insert  stopper,  avoiding  air  bubbles,  shake. 

Subtract  4  c.c.  from  volume  of  bottle  for  reagents  used. 

Allow  to  stand  ten  minutes. 

Run  in  5  c.c.  of  concentrated  HCl,  holding  pipette  just  above  the 
precipitate. 

Insert  stopper  and  shake. 

Free  iodine  is  liberated  and  a  clear  reddish  brown  fluid  obtained. 

Transfer  this  fluid  to  a  flask. 

Rinse  out  old  flask  with   10  c.c.  of  distilled  water  and  add  to  new 
flask. 

Run  in  this  from  a  burette  sodium  thiosulphate  solution  (4  grm. 
per  1,000  c.c.)  until  a  faint  yellow  colour  remains. 

Add  5  c.c.  of  fresh  starch  solution. 

Continue  with  thiosulphate  until  a  blue  colour  is  discharged. 

Now  do  a  blank  experiment  :  — 

In  a  flask  place  50  c.c.  of  KMnO^  solution  (i  c.c.  =o'oooi  grm.  O^). 
20  c.c.  of  H2SO4  solution  (i   in  4). 
10  c.c.  of  KI  solution  (10  per  cent.). 

Titrate  the  liberated  iodine  as  above. 

Suppose  the  blank  required  25  c.c.  of  thiosulphate. 

Suppose  the  sample  recjuired  15  c.c.  of  thiosulphate. 

50  c.c.  KMnOj  50  X  o'oooi  =  0*005  grm.  oxvgen. 

Hence  25  c.c.  thiosulphate  solution  0*005  grm.  oxygen. 

Hence  15  c.c.  thiosulphate  solution    oto5_x^j^  ^  p^^-, 

25         ^        "" 
The  volume  of  the  bottle  =  (224  -  4  c.c.)  220. 

In  220  parts  of  the  sample  there  are  grm.  0*003  of  O^;. 

T  .  r    .1  1       .^1  o-ooi  X    100, oco  r 

.  .    In    100,000  parts  01   the   sample   there   are —   =   i  30 

oxvgen  absorbed. 

A  good  water  should  have  about  I'l   parts  per  100,000. 


662  LABORATORY   HINTS 

Certificate  of  Analysis  of  a  Sample  of  Water. 

Date  received  : 

From  : 

Particulars  on  label  :   London  tap  water.     Taken  at  Laboratory 

Physical  characters  : 

Colour  in  2  ft.  stratum  :   clear  pale  blue. 

Suspended  matters  :   nil. 

Taste. 

Odour  when  warmed  to  37°  C.  :  nil. 

Reaction  :   alkaline. 
Chemical  characters  :  — 

Total  solids  dried  at  loo*^  C... 

Loss  on  ignition  (after  recarbonating) 

Chlorine... 

Chlorine  x   1,647  —  sodium  chloride 

Nitrites  (as  N2O3)         

Nitrogen  as  nitrates    ... 

Saline  ammonia 

Albuminoid  ammonia  ... 

Oxygen  absorbed  in  3  hours  at  37°  C. 

Hardness — Total 

„       — Temporary 

,,       — Permanent 
Poisonous  metals — lead 

!>  —copper     

,,  — iron 

TO  EXAMINE  SEWAGE  AND  SEWAGE  EFFLUENTS. 

The  same  processes  as  for  water  with  a  few  modifications. 
The  Ammonias. 

Dilute  sewage  five  times  when  estimating  the  ammonias. 
Make  100  c.c.  up  to  500  c.c.  with  ammonia-free  water. 
When  distilling  collect  200  c.c,  mix  well,  Nesslerize,  and  multiply 
the  result  by  4. 

It  is  best   to  collect   50  c.c.   more   to  see  that   no  more  ammonia 
remains. 

The  Solids  in  Suspension. 
The  estimation  of  these  is  required. 

Filter  1,000  c.c.  of  the  effluent  through  a  weighed  filter  paper. 
Wash  and  dry  the  residue  and  weigh  again. 
The  Rate  of  O,  Absorption  after  Filtration. 

Do  this  as  for  estimating  the  aeration  of  water,  p.  661,  but  tested 
at  different  times  :  — 

O,  absorbed  in  four  hours  at  60°  F. 

O,  absorbed  in  twentv-four  hours  at  60°  F. 

O2  absorbed  in  forty-eight  hours  at  60°  F. 

O,  absorbed  in  five  days. 


Parts  per 

IOD,000 

Grains  per 

gallon 

2  9 '60 

2072 

2*50 

175 

2-1 

1-47 

3-45 

Nil 

2-41 

0'12 

0-074 

Q-OGI 

0-0007 

0'007 

0*0049 

0-04 

0-028 

12-5 

8-0 

875 
5-60 

4-5 

Ml 

3-15 

Nil 

Nil 

THE   ANALYSIS    Of   MILK  663 

The  Ro)al  Commission  on  vSewage  Disposal  recommended  ihat  an 
effluent  "should  not  contain  more  than  3  parts  per   100,000  of  sus- 
pended matter;  after  being  filtered  it  should  not  absorb  more  than 
o'5  by  weight  of  O2  per  100,000  in  twenty-four  hours. 
I'o  b\'  weight  of  O.  per  100,000  in  forty-eight  hours. 
r5  by  weight  of  O2  per   100,000  in  five  days." 
Chlorine  should  not  exceed  10  parts  per  100,000. 
O2  absorbed  in  four  hours  at  60°  F.  (or  two  hours  at  80°  F.)  and 
the  saline  ammonia  should  not  exceed  1*5  per  100,000. 
The  albuminoid  ammonia  not  more  than  o'i5  part. 
Incubation  of  final  effluent  when  at  37°  C,  and  for  five  days  should 
be  odourless. 

Generallv  high  nitrates  are  a  good  feature. 

THE  ANALYSIS  OF  MILK. 
The  Average  Composition  of  Cow's  Milk  is : — 


Total  Solids  I2"6  per  cent. 


Water       ...        87*4  per  cent. 
Fat  ...  373     ., 

Lactose     ...  4*50     ,,  \ 

Proteins    ...  3"62     ,,  -  Solids  not  fat  8"87  per  cent. 

, Mineral  matters    075      ,,  ) 


The  specific  gravity  is  about  1032  at  15°  C. 

(1)  To  Estimate  the  Total  Solids. 

Weigh  a  small  porcelain  dish. 

Put  therein  10  c.c.  of  milk  and  reweigh. 

Evaporate  to  dryness  on  a  water  bath  for  one  hour. 

Dry  in  an  oven  for  one  hour. 

Cool  in  a  desiccator  and  weigh. 

Dish+  10  c.c.  of  milk    =  36*320  grm.  Dish  +  total  solids  =  27722  grm. 

Dish  =  26"4oo    „  Dish  =  26*400    „ 


Milk  weighs     ...       9*920  grm.  Total  solids     ...       1*322  grm. 

Hence  100  grm.  of  milk  will  contain  :  — 

=  13*32  per  cent,  of  total  solids 


1*322  X   100 


9*920 

(2)  To  Estimate  the  Ash  or  Mineral  Matter. 

Heat  the   residue   from   the  above   to  a   white  ash   on   a   porcelain 

triangle. 

Stir  with  a  glass  rod  meanwhile. 

Cool  in  the  desiccator  and  weigh.     Suppose  ash  is  o"076. 

100  grm.  of  milk  contains  about  o'76  per  cent. 

0*076  X   100 

9*920  (=  weight  of  milk)  =  76  per  cent. 

42 


664  LABORATORY    HINTS 

(3)  To  Estimate  Fat. 

Weigh  lo  c.c.  of  milk. 

Place  it  into  a  Stoker's  graduated  tube. 

Add  lo  c.c.  concentrated  HCI  and  heat  cautiously  till  brown. 

Cool  and  fill  up  to  the  50  c.c.  mark  with  ether. 

Shake  Avell  and  allow  ether  to  settle  out. 

Read  off  the  volume  of  ether,  say  26  c.c. 

Pipette  out  10  c.c.  of  ether  solution  into  a  small  weighed  glass  flask. 

Evaporate  ether,  dry  flask  in  oven  for  one  hour. 

Cool  and  weigh. 

If  a  Stokes  tube  is  not  available  heat  the  milk  in  a  large  test-tube, 
and  transfer  when  cool  to  a  graduated  100  c.c.  cylinder.  Wash  out 
the  tube  with  ether  and  place  same  in  the  cylinder,  and  the  volume  is 
now  made  up  to  50  c.c,  and  the  process  continued  as  described  above. 

Example : — 

Flask  fat  2y^yi 
Flask         23-421 


o'i5o 
In  10  c.c.  of  ether  there  is  o"i5  of  fat 
In  26  c.c.  of  ether  there  is  o"i5  x  26 

=  0-39 

10 
The  amount  of  fat  in  io"2i3  grm.  of  milk  (10  c.c.)  =  0*39 
The  amount  of  fat  in   loo  grm.  of  milk  0*39    x    o"ioo 


=  3"8i  per  cent. 


IO"23I 


(4)  To  Estimate  Solids  not  Fat. 

Subtract  the  fat  from  the  total  solids. 

Example :  i3'32  —  3"8i  =  9"5i  per  cent,  of  solids,  not  fat. 

(6)  To  Estimate  Lactose  (Fehling's  method). 

Pipette  20  c.c.  milk  into  a  100  c.c.  graduated  flask. 
Add  a  few  drops  of  acetic  acid. 

Mix  well,  place  on  a  water  bath  for  a  few  minutes. 
Cool  and  make  up  to  100  c.c.  with  distilled  water,  shake  and  filter, 
Fill  a  burette  with  this  solution. 

In  a  porcelain  basin  place  10  c.c.  of  Fehling's  solution. 
Add  40  c.c.  of  water  and  boil. 
Run  in  milk  solution  from  the  burette  slowly. 

Continually  try  a  few  drops  of  liquid  from  the  dish  with  a  starch 
and  KI  paper. 

When  it  ceases  to  give  a  blue  colour  stop  burette  flow. 

Keep  the  liquid  gently  boiling  during  the  process. 

For  the  indicator  it  is  handy  to  have  a  series  of  test-tubes. 

In  each  place  2  c.c.  of  the  indicator  and  one  drop  of  acetic  acid. 


THE   ANALYSIS   OF  MILK  665 

To  make  the  indicator  :  — 

Dissolve  o'5  grm.  of  starch  by  boiling  in  water. 
Dissolve  10  grm.  of  KI  in  water. 
Mix  and  make  up  to  100  c.c. 

Example :  j'l  c.c.  of  diluted  milk  were  required 

But  7*2  c.c.  of  diluted  milk  =  g"o678  grm.  lactose 
Since  10  c.c.  Fehling's  solution  =  o"o678  grm.  laciose 
Hence  100  c.c.  of  diluted  milk  =  o"678  x   100  grm.  lactose 

7-2 

But  this  is  in  20  cc.  sample  of  milk 

.•.  In  100  c.c.  sample  of  milk  =  0*0678  x   100  x   100 

=  47  per  cent,  lactose 

7-2  X  20 

(6)  To  Estimate  the  Specific  Gravity. 

This  can  be  estimated  by  Westphal's  balance,  the  Sprengel  tube 
lactometer,  or  the  specific  gravity  bottle.  The  lactometer  is  best  for 
tropical  use. 

It  is  usually  between  1028  and  1034. 

(7)  To  Estimate  Amount  of  Added  Water  and  Deficiency  of  Fat. 

These  are  obtained  from  two  simple  formulse. 
(A)  8-5    -   S.N.F.    X    100 


per  cent,  added  water 
8-5 

S.N.F.  solids  not  fat  found  in  sample,  e.g.,  27 

E.X8-5   -   7-5 

X   100  =  107  per  cent,  of  added  water 


8-5 

{B)3-F 


X   100  =  per  cent,  deficient  in  fat.     F.  =  fat  in  sample,  e.g.,  27 


J^X    o   2"7 

■ X   100  =  10  per  cent,  deficient  m  fat 

3 

(8)  Common  Preservatives  are: — 

(i)  Boric  Acid. 

Acidify  3  c.c.  of  milk  in  a  test-tube  with  distilled  HCl. 

Mix  well  and  place  a  drop  on  a  turmeric  paper. 

Dry  same  on  watch  glass  in  oven. 

A  red  spot  indicates  that  boric  acid  is  present. 

This  turns  green  instead  of  black  on  adding  caustic  potash. 

(2)  Formaldehyde. 

In  a  test-tube  place  10  c.c.  of  milk. 

Add   10  c.c.  of  concentrated   HCl   and  one  drop  of  ferric 

chloride. 
Stir  well,  heat  to  boiling. 
A  violet  colour  indicates  formaldehyde. 


666 


LABORATORY  HINTS 


Sale  of  Milk  Regulations. 

The  solids  not  fat  must  not  be  less  than  8'5  per  cent. 
The  milk  fat  must  not  be  less  than  3  per  cent. 
No  preservative  is  allowed  in  milk  of  any  kind. 

To  Analyse  Condensed  Milk. 

Employ  the  methods  already  mentioned  with  a  few  modifications. 
Use  a  ID  per  cent,  solution  of  the  condensed  milk. 
For  the  total  solids  and  proteins  take  15  c.c.  of  this  solution. 
For  the  fat  take  10  c.c.  of  this  solution. 

The  fat,  ash,  proteins  and  lactose  subtracted  from  the  total  solids 
give  the  cane  sugar. 

An  average  analysis  should  yield  :  — 


Water     ... 

25-2  per  cent 

Fat 

iro          „ 

Proteins ... 

9-07        „ 

Ash 

rgo        ,, 

Lactose  ... 

i3'4o        „ 

Cane  sugar 

•  ••      39-43 

I  OO'OO 

APPENDIX. 

FALLACIES    IN    BLOOD    EXAMINATION, 

THE    GENERAL     TREATMENT     OF     FEVER. 

EMBALMING. 

SOME    HINTS    ON    TROPICAL    SURGERY. 

COMPARATIVE    NORMAL    TEMPERATURES. 

PRINCIPAL    REFERENCES. 


668  APPENDIX 


APPENDIX. 

FALLACIES   IN   BLOOD   EXAMINATION. 
Conditions  leading"  to  fallacies  may  be  dealt  with  in  two  classes:  — 

(1)  External. 

Insect  hairs  may  simulate  filariae.  Low  and  Stiles  took  this  view  of 
the  F.  gigas  described  by  Proiit. 

Cotton  fibres  once  led  to  a  wholesale  diagnosis  of  filarije  cases. 

Care  and  cleanliness  should  exclude  these. 

Films  sent  from  the  tropics  may  contain  yeast  cells  or  spores  which 
may  cause  considerable  confusion. 

Less  troublesome  are  pollen  grains,  animal  and  vegetable  debris 
found  in  the  dust  fouling  the  specimen. 

Films  made  from  the  blood  of  shot  or  slaughtered  beasts  or  birds  may 
contain  parasites  carried  from  the  gastro-intestinal  tract,  skin,  hairy 
hides  or  feathers  of  the  cadaver. 

A  piece  of  blotting  paper  may  be  used  to  dry  one  slide  in  staining 
and  in  blotting  a  second  with  the  same  paper  some  of  the  parasites 
from  the  first  may  be  carried  to  the  second  slide. 

Flaws  and  cracks  in  the  glass  should  always  be  anticipated,  especially 
as  "seconds"  are  better  than  "firsts"  for  tropical  work,  as  the  best 
quality  slides  "fog"  readily. 

(2)  Internal. 

Fresh   Blood. 

Crenations  of  red  cells  are  readily  differentiated  from  parasites  as  a 
rule. 

Vacuoles  are  a  little  more  troublesome.  They  are  highly  refractive, 
never  show  granules  in  their  interior  and  exhibit  no  movements. 

Splits  and  cracks  in  red  cells  have  received  many  names  and  as  they 
appear  more  frequently  in  pathological  specimens  they  may  be  more 
readily  taken  for  hsematozoa.  They  have  no  amoeboid  movement  but 
the  contraction  and  the  coagulation  of  the  protoplasm  may  cause  them 
to  change  their  position  slightly.  They  have  probably  been  mistaken  for 
bodies  occurring  in  pernicious  anaemia,  leukaemia  and  lead  poisoning. 
The  so-called  Cropper's  bodies  may  be  of  a  similar  nature. 

Granules  from  broken-down  leucocytes  may  overlie  red  cells  and 
cause  trouble.     They  are  easily  differentiated   by  focusing. 

A  raised  temperature  may  cause  a  peculiar  degeneration  of  red  cells 
that  must  be  watched.  They  are  most  often  seen  when  one  is  working 
with  a  hremostat. 

A  blood  platelet  lying  on  a  red  cell  may  simulate  a  malarial  Plas- 
modium. These  can  soon  be  diagnosed  by  altering  the  light  and  by 
focusing. 

Blood   dust  may  be   confused   with   granular  debris   from  leucocytes 


THE    GENERAL    TREATMENT    OE   EEVER  669 

or  with  micrococci.  They  sometimes  appear  like  minute  fat  droplets, 
which  may  be  correct,  as  such  do  appear  after  a  meal. 

Under  artificial  conditions  lymphocytes  and  myelocytes  may  become 
flagellates,  induced  by  excitants  such  as  atropine,  methylene  blue  and 
a  cancerous  plasma. 

Normal  blood  has  shown  bodies  with  pseudopodia  supposed  at  one 
time  by  Koch  and  Kliene  to  be  associated  with  piroplasmosis.  They 
are  only  altered  blood  cells. 

Bodies  like  vesicles  in  red  cells  have  been  mistaken  for  a  special  form 
of  intra-corpuscular  spirochsetal  inclusion. 

Stained  Blood. 

Blood  platelets  on  red  cells  must  be  differentiated  from  the  malarial 
parasite,  and  a  mass  of  platelets  from  a  crescent  or  a  clump  of  spores  or 
Leishman-Donovan  bodies. 

The  corps  en  pessaire  and  corps  en  anneau  of  French  writers  should 
be  differentiated  from  pathological  findings  in  malarial  cachectics.  In 
such  patients  anticipate  endoglobular  and  anaemic  degeneration  of  the 
red  cells. 

The  degeneration  and  vacuolation  of  leucocytes  may  make  the 
student  almost  unaware  of  their  origin.  Experience  alone  will  aid  in  the 
process   of   differentiation. 

Oval  and  round  rings  occur  in  the  cytoplasm  of  lymphocytes,  probably 
under  the  influence  of  alkaline  stains,  &c. 

When  animal  blood  conditions  are  considered  the  subject  becomes 
much  more  comprehensive. 

For  details  upon  this  subject  the  student  is  recommended  to : 
"  Fallacies  and  Puzzles  in  Blood  Examination,"  by  Andrew  Balfour, 
M.D.,  in  the  Fourth  Report  of  the  Wellcome  Tropical  Research  Labora- 
tory, Vol.  A,  Medical,  of  which  the  above  is  an  abstract.  That  article 
will  be  found  sufificient  for  general  purposes. 

THE  GENERAL  TREATMENT  OF  FEVER. 

In  this  outline  of  treatment  the  specific  cause  of  the  fever  is  not  dealt 
with.  This  should  be  known  and  treated  accordingly,  but  in  all  fevers 
there  are  so  many  things  in  common  that  the  general  treatment  may  be 
along  similar  lines  for  all. 

When  death  takes  place  probably  the  chief  source  of  weakness  is  the 
heart,  hence  one  must  consider  those  factors  telling  against  the  circulation 
as  :  — 

Under  and   improper  feeding. 

Insufficient  water. 

Vomiting  because  it  withdraws  food  and  water  from  the  patient, 

is  exhausting  and  prevents  rest  and  sleep. 
Diarrhoea  for  the  same  reasons. 
The   breathing   of   foul   air. 
Insufficient  oxygen. 

The  interference   of  oxygenation   due  to   hmg   troubles. 
The  impairment  of  the  renal  secretion. 
The  loss  of  sleep  and  rest  due  to  noises,  bright  light,  pain,  toxaemia 

and  pyrexia. 
The  elevation  of  the  head. 


6/0  APPENDIX 

The  main  thing's  one  must  watch  and  deal  with  are  diet,  vomiting, 
diarrhoea,  constipation,  pure  air,  the  maintenance  of  oxygen  for  the 
blood,  sweating,  renal  secretion,  rest  and  sleep,  the  control  o(  pain, 
pyrexia,  elevation  of  the  head,  sustenance  of  the  heart  and  care  during 
convalescence.     These  will  now  be  dealt  with  seriatim. 

(1)  Diet. 

It  should  consist  of  carbohydrates,  proteins,  fats,  water,  sodium 
chloride  and  vegetable  salts,  in  a  word  it  must  be  complete.  The  feeding 
must  be  adapted  to  the  condition  of  the  patient  thus:  — 

The  patient  may  not  be  able  to  take  food  by  the  mouth  or  rectum 
owing  to  diarrhiea  and  vomiting,  hence  one  must  feed  by  giving 
salines  intravenously  or  subcutaneously  at  a  temperature  of 
100°  F.  in  the  funnel.  Give  at  least  one  pint  in  twelve  hours. 
This  is,  of  course,  not  a  complete  food  or  anything  like  it,  but 
it  is  the  best  that  can  be  done  for  the  time. 

The  patient  may  not  be  able  to  take  food  by  the  mouth  owing  to 
vomiting  but  can  take  it  by  the  rectum.  Then  give  peptonized 
milk,  100  c.c.  for  an  infant,  125  c.c.  for  a  child  and  250  c.c.  for 
an  adult  every  six  hours.  If  rejected  give  a  suppository  and 
repeat  the  food.  Raise  the  buttocks  to  assist  by  gravity  the 
entrance  of  the  food. 

Rectal  feeds  vary  enormously  as  regards  constituents  and  each 
will  use  that  which  in  his  experience  has  proved  most  useful. 

There  is  much  controversy  as  to  the  absorption  of  foods  per 
rectum  but  in  such  cases  as  those  mentioned  it  is  best  to  give 
them. 

When  the  patient  can  take  some  food  by  the  mouth  it  must  be  an 
incomplete  food  at  first,  such  as  junket,  raw  meat  juice,  white 
of  egrg.     Beef  teas  and  broths  are  not  good  foods. 

A  little  alcohol  in  special  cases,  albumen  water  and  whey. 

When  this  can  be  retained  begin  with  complete  foods  as  follows:  — 

No.   I   Diet. 

Milk  about  four  pints  in  twenty-four  hours. 

For  infants  during  the  first  six  weeks  of  life  2  water  and  i  milk. 
,.  ,,  second  six  weeks         i  ,,  i     ,, 

,.  ,,  next   four   months      i  ,,  2     ,, 

For   adults        ...         ...         ...         ...         ...     i  ,,  5     >> 

If  curds  are  formed  add  barley  water,  rice  water,  arrowroot 
water,  aerated  water  or  lime  water.  Add  sodium  bicar- 
bonate, 10  grains  (o"65  grm.)  to  the  pint  of  milk. 

The  milk  may  be  boiled  or  prepeptonized. 

Allenbury's  food  may  be  given.  A'egetable  juices,  as  lemon 
squash,  lime  juice,  &c. 

Nasal  feeding  may  be  required  in  some  cases. 

No.  2  Diet. 

Milk,  two  pints  daily  with  arrowroot,  cornflour,  rice,  tapioca 
and  bread.  Egg-  albumen,  cream  and  butter.  Stewed 
apples,  fresh  fruit,  tea  and  weak  coffee,  pounded  raw  meat. 
Beef  tea  and  soups. 


THE    GENERAL    TREATMENT    OF    FEVER 


6yi 


No.  3  Diet. 

No.  2  diet  plus  fish,  vegetables,  raw  oysters,  sweetbread,  tripe. 

No.  4  Diet. 

No.   3  diet  plus  meat,   as  pigeon,   chicken,   mutton,   beef,  and 
rarely  pork. 

Yomiting. 

Provide  digestible  food.  Reduce  the  quantity.  Feed  per  rectum. 
Apply  a  mustard  poultice  over  the  stomach.  Wash  the  stomach  with 
stomach  tube  and  sodium  bicarbonate. 


Diarrhoea. 

Examine  the  stools  for  foulness,  undigested  food, 
faction,  worms'  eggs,  parasites  and  treat  accordingly, 
good. 

Constipation. 

Give  a  mild  laxative. 
Enemata  are  useful. 
Petroleum  jelly  is  good. 

Give — 


excessive   putn- 
Salol   is  alwavs 


R    Salol 

OI.  ric. 
Muc.  acac.   .. 
Aq.  chlor.  ad 


OI2  grm. 

o'3o  CO. 

090  CO. 

30"oo  grm. 


Thrice  daily 


Pure  Air. 


Open  air  treatment  is  always  good. 

Prevent  draughts. 

Skilful  nursing  is  required. 


Maintenance  of  Oxygen  for  the  Blood. 

Keep  the  air  passages  open. 

Use  the  steam  jet  when  there  is  laryngeal  obstruction. 

A  cold  douche  or  bath  is  good  with  pulmonary  collapse  with  children. 

Tracheotomy  may  be  necessary. 

Sweating. 

This  is  of  minor  importance,  but  the  patient  should  be  washed  down 
with  tepid  water  when  the  perspiration  is  finished  and  chills  prevented 
by  suitable  clothing. 

When  there  is  a  persistent  dry  skin  with  a  high  temperature  then 
induce  sweating  by  hot  drinks,  blankets,  hot  bottles,  &c. 

Renal  Secretion. 

Apply  large  poultices  over  the  loins  every  four  hours. 

Dry  cupping  can  be  tried  but  it  is  less  effective. 

Give  fluids  in  sufficiency.  Salines  per  rectum,  i  to  2  pints  each  twelve 
hours.  If  children,  seat  them  in  a  hot  bath.  If  adults,  foment  the 
abdomen.     Test  the  bladder  with  a  catheter. 

For  Haemog'lobinuria,  see  p.  380. 


6y2  APPENDIX 

Rest  and  Sleep. 

Exclude  noise.     Have  a  dull  light  in  the  evening. 

For  insomnia  give  phenacetin  0*30  to  0'6o  grm.  at  eight  o'clock,   or 

^     Pot.  brom i  grm. 

Chlor.  hydrat.  ...     i     ,, 

Aq.  ment.  pip.  ad    ...   30     ,, 

For  a  child,  15  to  30  grm. ;  for  an  adult,  30  to  60  grm.  at  eight  o'clock. 
Trional  is  useful,  i  to  i'5  grm.  at  eight  o'clock. 

Morphia  may  be  necessary  at  times  but  it  is  often  followed  by 
depression. 

Control  Pain. 

Give  aspirin,  o'30  to  i  grm.  every  six  hours;  or  opium,  0*02  grm. 
every  six  hours. 

Pyrexia. 

If  the  temperature  is  above  103°  F.  reduce  it. 
If  it  is  above  106°  F.  reduce  it  immediately. 

Keep  the  wards  cool  for  typhoid,  warm  for  measles,  diphtheria  and 
whooping-cough. 

Give — 

I^     Quin.  hydrochlor.      ...     0-30  —  I'oo  grm. 

Phenacetin     ...         ...     o*i8  —  0*50    „ 

Thrice  daily. 

Hydrotherapy. 

Sponge  the  whole  body  with  hot  water  in  four  minutes  to  dilate 

the  blood-vessels. 
Or  a  tepid  sponge  in  fifteen  minutes. 
Or  a  cold  pack  twenty  minutes.     This  is  more  active  and  is  used  at 

once  in  high  temperatures  or  when  sponging  is  useless. 
Or  a  continuous  pack.     The  sheet  is  kept  moistened  v/ith  water  at 

90°  F.   for  several  hours  daily. 
Mackintosh  baths  can  be  given.     Ice  bags  can   be  applied. 
Children    and    the   aged   do    not    stand   baths    well    owing    to    the 

tendency  to  cardiac  weakness. 
As  a  last  resort  some  give  pilocarpine  nitrate  subcutaneously. 

Depress  the  Head. 

Avoid  the  elevation  of  the  head.  It  not  only  causes  muscular  stress 
but  as  the  Ijrain  is  not  well  supplied  with  blood  owing-  to  gravity  and 
heart  weakness,  depression,  fainting  and  syncope  may  ensue. 

Sustain  the  Heart. 

This  should  l)e  done  with  digitalis,  strophanthus.  strychnine,  camphor 
and  alcohol. 

Raise  the  foot  of  the  bed.     Give  salines.     Hot  bottles. 
Some  omit  digitalis  and  strophanthus. 

Watch  the  Heart  during  Convalescence. 

After  luemoglobinuria.  beriberi,  typhoid,  diphtheria,  &c.,  sudden 
heart  failure  may  occur. 


SOME  HINTS   ON  TROPICAL  SURGERY  673 

Watch  the  rate  and  rhythm,  a  weak  first  sound  at  the  apex  and  an 
accentuated  second   sound  in  the  aortic  area. 

Exercises  should  be  very  gradual.  The  blood  count  must  be  over 
3^-  millions  per  c.mm. 

EMBALMING. 

In  order  to  preserve  bodies  for  autopsy  inject  300  c.c.  of  5  per  cent, 
solution  of  formalin.  The  fluid  can  be  injected  into  the  large  arteries, 
e.g.,  the  femoral  and  brachial  towards  the  extremities,  the  common 
carotid  in  both  directions  and  the  cavities  and  organs  by  trocar  and 
cannula. 

A  more  elaborate  method  is  as  follows  :  — 

Prepare  10  litres  of  a  10  per  cent,  solution  of  mercuric  chloride. 
Expose  the  abdominal  aorta  and  both  iliac  arteries. 
Incise  the  aorta  and  tie  a  large  cannula  and  syringe  in  the  opening. 
Inject  3  litres  into   the   upper  part,   slowly  and   resting  when  the 

pressure  is  great.     Ligature  both  sides  of  the  opening. 
Inject  I  litre  into  each  leg  through  the  common  iliac  artery. 
Ligature  the   mesentery  and   intestines   from  the  jejunum   to   the 
sigmoid,  divide  and  remove  them.     Open  and  wash  them.     Put 
into  them  a  i  per  cent,  solution  of  mercuric  perchloride,  replace 
them  wrapped  in  sublimate  wool,,  or  better,  cremate  the  lot. 
Wash  the   stomach,   duodenum  and  rectum   in  the  same  way  and 
pack  with  sublimate  wool.     Treat  in  the  same  way  the  bladder, 
vagina,    external   ear,    nostrils,    &c.     Clean   out   the   abdominal 
cavity,  dry  it  and  sew  up  the  incision. 
Wipe  the  surface  of  the  body  with  the   same  solution  and  dry  it 

(the   hair  excepted). 
Some  also  inject  into  the  axillary  and  carotid  arteries. 

SOME  HINTS  ON  TROPICAL  SURGERY. 

All  surgical  instruments  and  appliances  must  be  of  the  best  quality 
obtainable.  People  at  home  sometimes  send  out  those  goods  not  readily 
disposed  of  at  home,  much  to  the  chagrin  of  the  tropical  surgeon  abroad. 
It  is  awkward  indeed,  if  when  attempting  to  remove  a  stone  from  the 
bladder,  one  of  the  jaws  of  the  instrument  breaks  off  or  bends  consider- 
ably. 

Vulcanite  and  gum-elastic  goods  should  be  avoided.  Rubber  rapidly 
perishes,  but  if  kept  in  water  in  a  dark  place  it  will  last  longer.  Rubber 
gloves  can  be  kept  in  a  glass  jar,  in  powder,  well  stoppered.  Catheters 
should  be  rubber  or  metal,  preferably  the  latter.  Rubber  tourniquets 
are  often  useless  when  most  urgently  needed.  Good  metal  ones  are 
now  made. 

Syringes  should  be  all  metal  or  all  glass.  If  they  are  made  of  two 
or  more  kinds  of  material,  the  unequal  alternate  contraction  and  ex- 
pansion will  cause  fracture  of  the  instrument.  All  needles  should  be  of 
irido-platinum.     They  keep  their  points  well  and  do  not  become  oxidized. 

Microscopic  slides  should  be  of  second-class  quality,  as  the  best 
quickly  "fog"  and  are  useless.  The  cover-sHps  should  be  of  the  best 
quality. 

Take   duplicates   of   fragile   instruments   likely   to    be   used   by   native 


674  APPENDIX 

assistants,  as  these  latter  are  usually  careless,  and  fresh  supplies  of 
instruments  may  require  months  to  obtain. 

.Ml  metal  goods  should  be  well  plated,  vaselined,  and  well  packed 
in  a  tin-lined  soldered  case  for  dispatch.  The  Customs  authorities 
usually  open  them  and  leave  them  open,  but  protection  has  been  afforded 
for  the  ocean  passage.  "  Air-tight  "  boxes  are  not  usually  air-tight, 
air  escapes  about  the  fastenings  owing  to  expansion  from  heat,  and  is 
usually  reabsorbed  in  a  moist  condition  when  the  atmosphere  becomes 
cool.     All  cases  should  be  tin-lined  and  well  soldered. 

^^e]vet-lined  cases  of  instruments  are  only  welcomed  by  cockroaches 
and  other  insects. 

The  anaesthetic  of  choice  is  chloroform.  Although  given  by  native 
assistants  over  thousands  of  administrations  very  few  accidents  occur. 
Ether  is  used  at  the  Ancon  Hospital,  Panama,  a  fresh  small  tin  being 
opened  for  each  case.  Tropical  workers  as  a  rule  find  that  ether 
evaporates  too  quickly.  Chloroform  should  be  dispatched  in  glass 
bottles,  with  glass  stoppers  well  .sealed.  Cork  perishes,  and  unsealed 
glass  stoppers  become  loose  in  transit. 

Intraspinal  ansesthesia  is  coming  to  the  fore.  Boyd  and  Young 
report  on  over  6,000  cases  at  the  Santo  Tomas  Hospital,  Panama  Canal 
Zone.  It  was  used  for  all  operations  below  the  umbilicus  and  sometimes 
for  the  upper  abdomen.  The  mixture  was  Stovaine  o'l  grm..  Sodium 
chloride,  o'l  grm.  in  i  c.c.  of  distilled  Avater.  Five  c.c.  were  usuallv 
given  for  operations  of  half  an  hour  or  less.  Anaesthesia  is  complete  in 
three  and  a  half  minutes  and  lasts  fifty  to  sixty  minutes.  It  was  preceded 
by  an  injection  of  morphia.  Cases  showing  a  low  blood-pressure  from 
shock  following  loss  of  blood  were  excluded. 

The  sepsis  of  wounds  is  much  more  prevalent  in  the  Tropics  than  in 
Europe,  as  conditions  are  much  less  perfect  and  operations  are  carried 
out  in  theatres  open  to  air  currents. 

The  treatment  of  fractures  is  difficult.  The  patients  are  usually 
restless,  the  skin  is  moist,  and  may  be  shed  in  cases  requiring  prolonged 
extension.  Adhesive  plaster  i.s.  seldom  adhesive,  and  plaster-of-Paris 
seldom  hardens  sufficiently. 

One  is  often  consulted  as  to  when  the  spleen  should  be  removed. 
The  writer  follows  Cantlie's  list :  — 

(i)  Rupture  of  the  spleen. 

(2)  Primaiy  hydatids. 

(3)  ,,         malignant  growth. 

(4)  M         abscess. 

(5)  >»         massive  tuberculosis  of  the  spleen. 

(6)  Chronic  splenic  anaemia. 

(y)         ,,         hsemolytic  (splenic)  jaundice. 
(8)  Banti's  disease. 

SOME  COMPARATn^E  NORMAT.  TE^FPERATURKS. 

Man      37'oO  C.  Cow      39"=^.^  C.  ' 

Cat        38-80  C.  Sheep 39-600. 

Dog      39-20  C.  Pigeon 42-0°  C. 

Goat     39-30  C.  Duck     42-2O  q 

Rabbit 39-50  C.  Chicken  ...  42-5O  C. 


PRINCIPAL  REPERENCES 


675 


PRINCIPAL    REFERENCES. 


"  A  Manual  of  Tropical  Medicine  "... 

"Tropical   Diseases"     ... 

"Tropical  Medicine  and  Hygiene"  ... 

"The  Principles  of  Hygiene" 

"  Laboratory  Studies  in  Tropical  Medicine 

"  Yellow  Fever  and  its  Prevention  " 

"  The  Prevention  of  Malaria  " 

"  Sleeping  Sickness  in  the  Island  of  Principe 

"  Trypanosomes  and  Trypanosomiasis  " 

"  Venoms,  Venomous  Animals,  &c." 

"Medical   Entomology"  

"  Recent    Advances    in    Tropical    Medicine" 
"  Review    of   Recent   Advances    in   Tropical 

Medicine"      

"Diseases  of  China" 

"  Amoebic  Dysentery  "  ... 

"Sprue  and  its  Treatment"    ...  

"Beriberi"  

"Human  Intestinal  Protozoa" 
"Researches    on    Egyptian    Bilharziasis "  ... 
"  The  Animal  Parasites  of  Man  "      

"Gnats  or  Mosquitoes  "  

"Hygiene  Coloniale  " 

"The  Etiology  of  Relapse  in  Malarial  Fever" 

"  Notice  sur  les  Glossines  ou  Tsetses  " 

"  Infant  Feeding  in  the  Tropics  "       

"Manual  of  Bacteriology"     

"  Hygiene  and  Public  Health  "  

"Diseases  of  the  Skin"  

"Nutrition"  

"  Diseases  of  the  Eye  " 

"The    Extra-Pharmacopoeia"  

"  Food  Analysis  "  

"Food  and  Hygiene" 

"  Reports    of    the    Sleeping    Sickness    Com- 
mission 

"  The  Classification  and  Pathology  of  Beri- 
beri "    

"  Album  of  Photographs."     B.M.A.  Indian  Section. 
Annals  of  Tropical  Medicine  and  Parasitology. 

Tropical  Diseases  Bulletin. 

Transactions  of  the  Society  of  Tropical  Medicine  and  Hygiene. 

Journal  of  Tropical  Medicine  and  Hygiene. 


Castellani  and  Chalmers. 

Manson. 

Daniels. 

Simpson. 

Daniels  and  Newham. 

Boyce. 

Ross. 

Bruta  da  Costa,  &c. 

Laveran  and  Mesnil. 

Calmette. 

Alcock. 

Balfour  and  Archibald. 

Balfour  and  Archibald. 

Jefferys  and  Maxwell. 

Carnegie  Brown. 

Carnegie  Brown. 

Vedder. 

Wenyon  and  O'Connor. 

Leiper. 

Fantham,     Stephens     and 

Theobald. 
Giles. 

Alliott,   Clarac,   8:c. 
James. 


Hegh. 

Decks. 

Hewlett. 

Whitelegge  and  Newman. 

Morris. 

Sohn. 

May  and  Worth. 

Westcott. 

Woodman. 

Tibbies. 

Mott. 


Wright. 


676 


INDEX 


I  NDEX. 


Abdomen  in  typhoid  fever  in  the  tropics, 

217 

Abscess,  evacuation,  in  filarial  lym- 
phangitis,  281 

Abscesses,  filarial,  282 

site  of,   282 

Abyssinian  well  for  shallow  Avater  in 
tropics,    551 

Acanthokeratodermia,   459 

Acariasis,  infected  barley  causing,  459 

symptoms,   459 

Acarina,  order  of,  ticks,  largest  speci- 
mens of,   19 

Acclimatization  theory  of  protection 
formed  by  vaccines  and  sera,  600 

Acid-fast  method  for  staining  micro- 
organisms,   614 

Ackee   poisoning,    aetiology,    455 

high   mortality   in,   456 

pathology,    456 

•  prophylaxis,  456 

symptomatology,   455 

{vomiting  sickness  of  Jamaica),  455 

Acne-like    eruption,    produced    by    spar- 

ganum,   261 
Acnitis,  treatment,  460 
Acrodermatitis  chronica  atrophicans,  460 

vesiculosa  tropica,   460 

Acrodermatosis,  460 
Actinomyces,  diagnosis  of,  629 
Adrenalin  in  sprue,  360 

injections  in  snake  bite,  445 

Aeration  of  waters,  methods  of  estimat- 
ing, 661 

Africa,  poisonous  snakes  in,  431 

West,    mortality   from   yellow   fever 

in,  370 

West  Coast  of,   loss  of  memory  in, 


539  .... 

After  cataract,  discission  for,  522 

Agar-agar,  preparation  of,  622 

Agarsidae    (tick),    spirochaetes    of    Miana 

fever,  &c.,  transmitted  by,   19 

Agglutinins,  action  of,  Coo 

in  snake  venom,  440 

Aglypha,  423 

Ainhum,  definition,  412 

pathology,  412 

symptomatology,   413 

Air,  hot,  as  means  of  disinfection,  593 
"Alastrim"  and  chicken-pox,  differentia- 
tion between,  401 

symptomatology,  403 

Albinism,  461 

Alcohol,  effect  of,  in  Tropics,  459 

medicinal  value  of,  583 

Alcoholic  drinks,  avoidance  in  sprue,  359 

stimulants,     strong,     avoidance     in 

yellow  fever,  371 


Alga;,    growth    of,     in     standing    water, 

method  of  removal,  547 
Alimentary  tract  of  fleas,  178 
Alkalies,  effect  in  sprue,  360 
Alopecia,  469 

treatment,  470 

by  external  irritants,  470 

by  nourishing  ointment,  470 

Alum,  rectal  injections  in  oxyuriasis,  313 

stick  in   trachoma,    515 

Amblyopia,    quinine    and    malarial,    dif- 
ferentiation between,  525 

toxic,  510 

Ammonia,  albuminoid,   in   water,   method 
of  estimating,  660 

and  ether  in  snake  bite,  445 

free  and  saline,  in  water,  method  of 


detection     of. 


estimating,  659 

Ammonias      in      sewage, 
method,  662 

Ammonium  chloride  in  treatment  of  tape- 
worms, 269 

Amocbiasis,  urinary,  41 

Amok,   407 

exciting  causes,  407 

Amputation  in  treatment  of  Madura  foot, 

482 
Anaemia      and      intestinal      irritation      in 
Hymenolepis  nana  infection,   263 

grave,  in  blackwater  fever,  387 

in  African  trypanosomiasis,   142 

in    verruca    peruana    (severe    type), 

364 

severe,     with     fever     produced     by 

Dibothriocephalus  latus,  260 

Anaerobic   cultures,   624 
Anaesthetics  in  eye  diseases,  528 
Anderson,  effects  of  hot  climates  on  white 

men,   538 
Anderson's  process,  sterilization  of  water 

^3y,  556 

Anemones,  venomous,  448 

sting  from,  symptoms,  449 

treatment,  449 

Aneurism,  late  manifestation  of  yaws,  25 
Angio-fibroma  contagiosum  tropicum,  461 
Angiomata,  502 
Angio-sarcoma,   502 

Animal  matter  in  water,  danger  from,  552 
Animals,  epidemic  gangrenous  rectitis  in, 
408 

living,  examination  of,  573 

Ankylostoma  duodenale,  points  of  differ- 
ence between,  and  the  Necator  ameri- 
canus,  320 

Ankylostomes,  314 

Ankylostomiasis,  blood  examination  in, 
317-8 


INDEX 


677 


Ankylostomiasis,  complications,  318 

life-history,  3i() 

prophylaxis,  318 

spread  of,  factors  necessary  for,  543 

■ symptomatology,  317 

treatment,   318-g 

Ankylostomum  duodenale,  314-5 
ova  of,  637 

Anopheles  maculipennis,   larva  of,  295 
Anthrax  bacillus,  diagnosis  of,  616 
Anti-bacterial  action,  how  produced,  164 
Antibactericidal     substances,     probability 

of,  in  snake  venom,  441 
Antibodies,  600 
Antidote,  or  retention  theory  of  protection 

afforded  by  sera  and  vaccines,  600 
Antidysenteric     serum,     summarizing     of 

work  by  Flexner,  201 
Antifibrin  ferment  in  snake  venom,  441 
Antigens,  600 

Antihasmolysins  in  snake  venom,  441 
Antimony  in  kala-azar,  61 

preparations  in  treatment  of  African 

trypanosomiasis,  148 

Antitoxic  sera,  599 
Antitoxins,  163 

Antityphoid    vaccine,    effect    on    case    in- 
cidence  and   case   mortality  of   typhoid 

fever,  601 
protection    afforded    b\-,    length 

of,   601 
Antivenene  in  snake  bite,  446 
Ants,  venom  of,  symptoms,  452 
Anuria  in  yellow  fever,  treatment,  371 
Appetite    perverted    in    cerebral    stage   of 

African  trypanosomiasis,   145 
Archibald's  fever,  definition,  397 

symptomatology,  397 

Archibald    and    Balfour,    bacteriological 

examination    of    river    and    well    water 

in   Khartoum,   642,   643 
Archoplasm  in  protozoa,  3 
Argas  persicus   (tick)  attacks  poultry  and 

humans,  21 
Arm,  elephantiasis  of,  293 
Arrow  poisons,  treatment,  457 
Arsenic    emetic   in    treatment   of  African 

trypanosomiasis,    149 

in  afebrile  splenomegaly,  417 

in   lichen  planus,   475 

in  onyalai,  417 

in  psoriasis,   487 

Arsenical  poisoning  in  zetiologv  of  beri- 
beri, 337 

preparations  in  treatment  of  African 

trypanosomiasis,    148 

treatment  in  rat-bite  fever,  398 


Artesian  wells,  551 

Aryan  races,  vegetarianism  of,   566 

Ascariasis,   definition,   309 

geographical   distribution,  309 

parasite  causing,  309 

symptomatology,  311 

treatment,  311 

Ascaris      lumbricoides,     examination 


of 


faeces  for  eggs  of,  311 

life-history,  309,  311 

morphology,  309,  310 

ova  of,   637 

parasite  causing  ascariasis,  309 


Asia,  poisonous  snakes  in,  428 
Aspergillinas,  diagnosis  of,  630 
Aspergillosis,  461 

ocular,  due  to  fungi,  511 

Aspirin  in  filarial  lymphangitis,  281 

in  phlebotomus  fever,  361 

in  yellow  fever,  371 

Asthenia  in  African  trypanosomiasis,   142 
Asthenopsia,   sponge-fishers',   509 
Atoxyl   in  pellagra,  336 

in     treatment    of    African     trypano- 
somiasis, 148 

Atripliasmus,  454 

symptoms,   454 

Antigens,  600 

Auchmeromyia  luteola,  larvae  of,  causing 

myiasis,  483 
Auto-intoxication  in  aetiology  of  beriberi, 

340 
Aviation,  dangers  of  atmospheric  changes 

in,  532 

Babesia  hominis,  6 
Bacilli,   162 

capsulated,  618 

characters  of,   1C2 

Bacillus  asiaticus  fever,  symptomatology, 
397 

botulinus,  diagnosis  of,  617 

coli,    diagnosis   of,   618 

— ■_ in   water,    quantity  of,    testify- 
ing to  measure  of  purity  of,  652 

enumeration     by     method 


of  British  sanitarians,  651 

diphtheriae,  diagnosis  of,  619 

lepras,    180 

diagnosis    of,    616 


mallei,   diagnosis  of,   621 

oedematis    maligni    (Bacillus    septi- 

cus),   diagnosis  of,   617 

of  timothy  grass,  diagnosis  of,  616 

paratyphosus  A,  geographical  distri- 
bution, 215 

-  paratyphosus  B,  geographical  distri- 
bution, 214 

-  pestis,  behaviour  of,   168 

carried  by  fleas,    177 

characters,  168 

cultures   of,    170 

diagnosis  of,  619 

habitat,  168 


—  pseudo-tuberculosis  of  Pfeifl'er,   dia- 
gnosis of,  616 

—  pyocyaneus,  diagnosis  of,  620 

—  typhosus,    diagnosis   of,    619 
vibrio     in      flies,     transmission     of 


cholera  by,  206 

welchii,  diagnosis  of,  617 


Ascites,  chylosus,  284 

■ in  filariasis,  279 


Bacteria,  death  of,  how  produced,  163 

demonstration      of,      in      laboratory 

work,  626 

detection  in   faeces,  635 

diseases  due  to,   161,   162 

distribution,    164 

entrance  into  tissues,    165 

general  features  of,   162 

in  aetiology  of  pellagra,  331 

in  waters,   examination  by  methods 

of  British  sanitarians,  650,  651 

infection     by,     conditions    necessary 

for,  164 

life  of,  conditons  necessary  for,  163 


678 


INDEX 


Bacteria,  mclliods  uf  locomotion,  162 

non-pathogenic,   in    water    cause    of 

muco-enteritis,  553 

physiology,    162,   163 

reproduction  by  simple  fission,  162 

by  spore  formation,  162 


resistant  to  effects  of  sunlight,  645 

■ shape  of,   162 

staining  for,  604 

susceptible  to  effects  of  sunlight,  645 

Bacterial  activity,  products  of,   163 

• emulsions,  509 

Bacteriolysins,   164 

Balantidium  coli,   7,  40,  45,  46 

parasite  of  ciliary  dysentery,  44 

— —  minutum,  7,  46 

Balfour  and  Archibald,  bacteriological 
examination  of  river  and  well  water 
in  Khartoum,  642,  643 

Balkan  War  (1913),  vaccination  against 
cholera  during,  results,  213 

Banana  flour  in  infant  feeding,  582 

Bandaging  in  elephantiasis  of  legs,  286 

Barcoo  rot,  461 

Basic  stains,  604 

Beans  causing  favism,  389 

Beef  broth  as  nutrient  medium  for  cul- 
tures, preparation  of,  621 

Bees  and  wasps,  sting  of,  symptoms,  452 

treatment,  452 

venom  of,  451 

Beetles,  venomous,  453 

Belladonna,  application  in  climatic  bubo, 

4"  .         . 

Benzoic  acid  and  sodium  benzoate  as  pre- 
servative, test  for,  577 

Beriberi,  aetiology,  2:^7 

atrophic,    dry   or    paralytic    variety, 

343,  344 

deficiency  disease,  337 

definition,   336 

diagnosis,  347 

dietetic  causes  of,  571 

geographical  distribution,  336-7 

history,  337 

hypertrophic,     wet     or     oedematous 

variety,  345-6 

infantile  variety,  347 

mixed  variety,  346-7 

oedematous  variety,  344 

pathology,  341 

post-mortem  examination,  341,  343 

prognosis,  349 

resemblances  to  and  differences  from 

epidemic  dropsy,  348-9 

spread  and  onset  of,  prevention,  540 

treatment,  349-50 

varieties,  343 

wet,  acute,  346 


Berkefeld  filter,  558 

Beta-naphthol  treatment  of  ankylostomia- 
sis, 319 

Beverages,  kinds  of,  causing  pain  in 
sprue,  357 

Big  heel,  course  of,  412 

geographical  distribution,  412 

treatment,  412 

Bile,  leaking  tumour  discharging  fluid 
giving  reaction  of,   501 


Bilharzia  Mission  (1Q15),  conclusions  as 
to  prevention  and  treatment  of  schisto- 
somiasis based  on,   249,   250 

Bilharziasis,  transmission  of  molluscs 
essential  for,  543 

Binary  fission,  asexual  method  of  repro- 
duction in  protozoa,  3 

Biotripsis  (life-wear),  461 

Bismuth-milk  treatment  in  amoebic 
dysentery,  43 

iodide  (emetine)  in  amtebic  dys- 
entery, 43 

Black  tongue,  476 

Blackwater  fever,  blue  pigment  in,  628 

diagnosis      of      yellow      fever 

from,  370 

■ — presumed  cause  of,  6 

see  also  H anioglohinnric  fever 

Bladder,      post-mortem      appearance      in 

schistosomiasis,  245,  246 

stricture  in  schistosomiasis,   248 

Blastomycetes,  diagnosis  of,  631 
Blastomycosis,  diagnosis,  462 

ocular,  due  to  fungi,  511 

symptomatology,   461 

treatment,  462 

Blindness,  508 

• •  causes  classified,  508 

due  to   lightning,  510 

Blood,  acidity  of,  in  cerebral  stage  of 
African  trypanosomiasis,   145 

cells,    abnormal,   605 

red,  abnormal,  606 

• counting  of,  606 

ha^mophilic,   606 
nucleated,  606 


transitional,  605 
white,  abnormal,  605 
counting  of,  607 


of, 


changes  in,   173 

staining  for,  604 

condition  in  verruga  peruviana,  364 
condition  in  yellow  fever,  367 
count,    differential    normal,    results 
605 

counting  of_,  606,  607 

in  varieties  of  malarial   fever, 

609,  610 

—  detection  in  faeces,  635 

—  dust,  60; 

—  effects  of  tropical  climates  on,  537 

—  examination  of,  604 
in   ankylostomiasis,   317 

—  films,  fixation  of,  605 

—  fresh,    examination    of,    for   micro- 
filariae, 610 


—  in  blackwater  fever,  387 

—  malaria-infected,    injections    of,    re- 
sult,  72 

—  malarial  parasites  in,  72,  73 

—  serum,  as  nutrient  medium,  prepara- 

—  specific     gravity      of,      method      of 
estimating,   612 

—  spectroscopic  examination  of,  612 

—  state  of,  in  sprue,  357 
tonicity  of,  613 


tion  of,  623 
Boiling  in   sterilization 
Boils,  treatment,  462 
tropical,  462 


of  water,   558 


INDEX 


679 


Bone-marrow  in  blackwater  fever,  386 

microscopical  appearance  in  African 

trypanosomiasis,   139 

Bone     sarcoma,     cystic     (myeloid  ?),     of 

lower  jaw,  4gg 
Bones  and  joints,  how  affected  in  chappa, 

413 

Boomerang  leg,  aetiology,  415 

geographical  distribution,  415 

symptomatology,   415 

Borax  methylene  blue  for  staining 
malarial  parasite  in  blood,  608 

Bore  well,  drill  for  producing,  551 

Boric  acid  and  borax  as  preservative, 
test  for,  578 

Bothriocephalus,   ova  of,  638 

Botryomycosis   hominis,   462 

Boyce's  summary  of  prophylactic 
measures    against    yellow    fever,    372 

Brackish  water,  ill-effects  of,  553 

Brain,   amoebic  suppuration  of,  40 

malarial    parasites    in,    manner    of 

demonstrating  in  laboratory  work,  627 

— ^ —  pernicious  manifestations  of  malaria 

in,    74 

Breast,   elephantiasis   of,   2gi,  293 

British  sanitarians,  methods  of  examina- 
tion of  bacteria  in  waters,  651 

Bromidrosis,  462 

Bronchocele,   fibroid,   498 

Bubo,  climatic,  aetiology,  410 

bacillus  isolated  from,  410 

definition,   410 

geographical  distribution,  410 

pathology,   411 

symptomatology,   411 

treatment,   411 

see  also  Plague  bubo 


Bucket  system  and  European  latrines,  588 
Bugs,  venom  of  451 

Building   sites,    suitable    in    tropical    dis- 
tricts,   535 
Burns  and  scalds  of  eye,  509 
Bush,   the,   as  latrines  for  natives,  585 
Butter,  adulteration  of,  571 
Butter-milk,    ^68 
Buttock,  elephantoid  tumour  of,  287 


C^COSTOMY  in  amoebic  dysentery,  43 
Caecum,  section  from,  in  case  of  amoebic 

dvsentery,   33 
Caffeine  injections  in  snake  bite,  445 
Calabar    swellings,    definition,    299 

geographical  distribution,  299 

symptomatology,   299 

treatment,   300 

Calcium  carbonate  in  sprue,  360 

hypochlorite,   use  in  purification   of 

water,    555 

lactate   for  viper   venom,   445 


Calomel  in  oxyuriasis,  313 

Calorie  value  of  foods,  565 

Canities,  470 

in  young  persons,  treatment,  pre- 
scription   for,  470 

Cantlie,  Sir  James,  nature  of  climatic 
bubo,  410 

Cantlie's   treatment   of   sprue,   359 

Carbohydrates,   food  value  of,  563 

43 


Carbol  fuchsin,  use  of,  as  stain,  604 
Carbol-thionin      for      staining      malarial 

parasite  in  blood,  608 
Carbolic  acid  as  disinfectant,  594 
Carbon  dioxide  poisoning  in  aetiology  of 

beriberi,  337 
Carbonates,    alkaline,    excess    in    water, 

eft'ects   of,    553 
Carcinoma,   melanotic,   495 

of  cervix,  502 

of  ovary,    502 

of   pylorus,    502 

Cardiac    and    vascular    tonic,    probability 
of  in  snake  venom,  441 

insufficiency  in   yellow  fever,   treat- 
ment, 371 

symptoms    in    South   American    try- 


panosomiasis,  157 
Carrion's    fever,    see    Verruga   -perjiviaiia 

(severe   type) 
Cassava  plant,   varieties  of,   564 
Castor  oil  in  amoebic  dysentery,  42 
in    ciliar    dysentery     (Balanti- 

dium  coli),  46 

seeds,  poisoning  by,  454 


Cataract,   509,  510 

• classification,  517 

congenital    and   juvenile,    complete, 


521 


discission    (needling)    for, 


521 


extraction  of,  complications,   521 

operation,   520 

■  in    India,    510 

■ lamellar  or  zonular,  518 

nomenclature,    517 

polar,  anterior,  or  pyramidal,  518 

posterior,    518 

■ senile,  518 

stages  in  growth  of,   519 

tests  for  time  of  operation,  519 

•  treatment  by  extraction,   519 

traumatic,    521 

uncommon   forms   of,   518 

Cataracts,   eye  complications   leading  to, 

Catarrh,  intestinal,  resulting  from  Stron- 
gyloides   stercoralis   infection,   271 

Catchment  areas  for  water  supply,  547 

avoidance  of  peat  in,  547 

Caterpillars,  venom  of,  symptoms,  452 

treatment,    452 

Cauterization   of   tropical   ulcers.    505 

Celluloidin,  embedding  In,  of  section  of 
malarial  parasites  in  brain,  627 

Centipedes,  venom  of,  mortality  in  chil- 
dren,   451 

symptoms,   451 

treatment,  451 

Centrosomes,   in   protozoa,   3 

Ceratophyllus  fasciatus,  transmission  of 
plague  by,   171 

Cercomonas  hominis,  habitat,  5 

vaginalis,  habitat,  5 

Cerebral  stage  in  African  trypanoso- 
miasis,   144-6 

Cerebrospinal  system,  microscopical 
apoearance  in  African  trypanosomiasis, 
138 

Cesspools  in  tropics,   589 


68o 


I^'DEX 


Cestoda,    classification,  258 

life-history,   258 

morphology,    257 

pathogenic  to  man  (human  tape- 
worms),  257 

Cestode,  onchosphere  of,  637 
Cestodes,  preservation  of,  323 
Chappa,   pathology,  413 

treatment,  413 

Chaulmoogra  oil    in    leprosy,    188 
Chaulmoogric  acid  in   leprosy,    188 
Cheek,  epipthelioma  of,  fungating,  papil- 
lomatous, 500 

horny  growth   from,   504 

Cheese,    whole    milk,    most    nutritious    of 

all   foods,   567 
Cheilitis   exfoliativa,   476 

glandularis,   476 

Cheiropompholyx,  463 

treatment,  463 

Cheloid,   502 

causes   of,    502 

Chemicals  used  for  testing  water  sus- 
pected  of  contamination,    553,    554 

Chicken-pox  common  in   India,  401 

Children,  Davainea  madagascarensis  in- 
fection in,  263 

intestinal     ulceration     and     anaemia 

resulting    from    infection    by,    in    chil- 
dren,  263 

men  and  women,  food  necessary  for, 

compared,    564 

of     natives,     epidemic     gangrenous 


rectitis,   in,  408 

very  young,  alone  affected  by  ponos, 


413 


fever   in,   368 
Chlamydophrys  stercorea,  habitat,  5 
Chloasma,  causative  agents  of,  463 

varieties  of,  463 

Chloride,  cold,  in  snake  bite,  446 
Chlorine  as    disinfectant   for   horses,    jjgC 

in    water,    detection   and    estimation 

of,   method,   655 

sterilization  of  water  by,   557 


Cholera,  aetiology  of,  205 

carriers  of,  213 

transmission  of  cholera  by,  206 

collapse  of,  treatment,  210,  211 

complications   of,    208 


—  definition    of,    203 

—  development  of,  climatic  conditions 
best  suitable  for,   539 

—  diagnosis  of,  208-Q 
bacteriological,  2og 


epidemics  in  Europe,  203-4 

relation  of,  to  wars,  204-5 


—  geographical  distribution  of,   203 

—  modes  of  infection,  205 

-—  or  plague  on  infected  ships,  cjuaran- 
tine  measures  respecting,   597 

—  organisms,     removal     from     Avater, 
chemical    process   for,    556 

—  pathology  of,  206 

—  post-mortem  appearances,  206-7 

—  prophylaxis  against,  212 

—  spirilla,  2oq 

—  symptomatology  of,  207-8 

—  treatment,  20Q,  210 

— -  by  Rogers'  method,   210 


Cholera,   treatment,   indications   for,   209 
old     and     new     methods    com- 
pared,  211 

vaccination  against,  results,  212,  213 

vibrio  in  milk,  tests  for,   570 

vomiting  in,  treatment,  210 


Chondroma,   505 
Chondrosarcoma  of  humerus,   498 
Chromidiosomes  in  protozoa,  3 
Chrysarobin      ointment,      application      in 
various  forms  of  tinea  (ringworm),  490, 

491,  493,  494 

Chrysomyia      macellaria      (screw-worm), 
larva  of,  causing  myiasis,  482 

Chrysops   dimidiata    and    silacea,    carrier 
of  Loa  loa. 

Chyle,  double  conjunctivitis  discharging, 
associated  with  hlaria  infection,   294 

Chylocele,  284 

Chylous  extravasations,  282,  283 

in  frlariasis,  279 

Chyluria     and      lymphuria,      symptomat- 
ology,  283 

treatment,  284 


natural     immunitv     to     vellow 


in   filariasis,   279 

Ciliata,    5,    7 

(infusoria),    5 

Cimex    lectularius    (bed-bug),    carrier    of 
parasite  of   European   relapsing   fever, 
10 
Cirrhosis,   biliary,   pathology,   410 

infantile,  409 

■ aetiology,  409 

cause  of  death  in,  410 
symptomatology,  409 
treatment,  410 


resemblance  of  ponos  to,  413 
treatment,   410 


Clarke's  process  for  softening  water,  555 
Clayton  apparatus,  use  of,  for  extensive 
fumigations  with  sulphur  anhydride 
and  sulphurous  acid  gas,  595 
Clemesha,  Major,  methods  of  bacterio- 
logical examination  of  waters  in  India, 
645,  646 

classification    of    river    waters    for 

drinking  purposes,  649,   650 

Climate,   definition,  531 

effect  of,   on   skin,   458 

relation  to  tropical  diseases,  539 

Clonorchis  sinensis,  ova  of,  637 
Coast   memory,    539 

Cobra  seizing  prey,  photograph  of,  424 
Cocci,  shape  of,   162 

Coccidium  oviformis,  diseases  caused  bv, 
6 

habitat,  6 

Cocoa,  ciualities  of,  583 
Cod-liver  oil  in  onyalai,  417 
Coffee,  qualities  of,   582-3 
Collargol  in   five-day  fever,  398 

solutions  of,  in  treatment  of  African 

trypanosomiasis,   149 

Colon,   dysenteric  ulceration  of,  healing, 

^35      . 
Colubridae,   423 

orders   of,   423 

Colubrine     venom      (snake     bite),     post- 
mortem, 442 

symptoms,  441,  442 


Coma   in  ackee  poisoning,  456 


INDEX 


68 1 


Comma  bacillus,  cause  of  cholera,  205 

Koch's,  621 

differentiation  from  Fink- 

ler-Prior  spirillum  (Vibrio  proteus),  621 
Compound    tablet,    sterilization   of    water 

by,    557    .  .  .      ,.     ,       . 

Conjunctivitis  aestivalis    (spring  catarrh), 

516 

and  keratitis,  phlyctenular,    516 

■ ,  treatment,  516 

astringent  remedies  for,  526,   527 

—  catarrhalis,   511 

. double,  discharging  chyle,  associated 

with  lilaria  infection,  294 

gonorrhoeal,    510,   512 

resulting   from  unclean  habits. 


510  .  ,       . 

Connective  tissue  tumours,  benign,  502 

malignant,  502 

Continents,  new  means  of  intercourse 
between,  opening  of,  increasing  study 
of  transmission  of  communicable  dis- 
eases,  543 

Convulsions  in  ackee   poisoning,  456 

Coolie  itch,  treatment,  463 

Copper  in  water,   method  of  estimating, 

sulphate,  test  for,  579 

pencil   in   trachoma,    514 

sterilization   of  water  by,    557 

Copra  itch,   463 

Corals,  venomous,   448 

• sting  from,  symptoms,  449 

Cordylobia  anthro])haga,  larvre  of,  caus- 
ing myiasis,  482 

Cordylobiasis,  464 

Cornea,  abrasions  of,  509 

Countries,  new  means  of  intercourse  be- 
tween, opening  of,  increasing'  study  of 
transmission  of  communicable  diseases, 

543 
Cover  slips,  method  of  cleaning,  604 
Cox's  method  of  treatment  of  cholera,  211 
Craw    craw    (nodular    dermatitis),    treat- 
ment,  464 
Creeping    disease    or    erui^tion,    difficulty 

of  treatment,  464 
Crocidura    coerulea     (Indian    musk    rat), 

resistent  to  plague,  171 
Crotalinae,  426,  431 

in   America,    435 

Crotaline  venom   (snake  bite 


i43 


symptoms, 
mottled 


Crotalus   confluentus   (Pacific   or 
rattlesnake),   429 

terrificus  (dog-faced  rattlesnake),  428 

Culex  fatigans,  breeding  places,  295 

carrier  of  filaria,  294 

larvse  and  pupae  of,  294,  295 

morphology,   294 

transmission  of  dengue  by,  376 

Cultures,   differentiating   growth,  624 

preparation  of,  621 

Current  steam  disinfector,  593 
Cycloplegics  in  eye  diseases,  528 
Cyclops    quadricornis,    intermediate    host 

of     Dracunculus     medinensis     (guinea- 
worm),   301 

Cyllin  as   disinfectant,    594 

Cytolysins,   action  of,   600 

in  snake  venom,  four  groups  of,  440 


Daniels,  diagnosis  of  microfilaria,  277 

tests  for  bacteriological  examination 

of   water,   642 

Darling,  discovery  of  Histoplasma  capsu- 

latum   by,   6 
IDavainea  madagascariensis,   infection    in 

children,   263 
Dengue,  aetiology,  377 

definition,    376 

diagnosis,  378 

of  phlebotomus  fever  from,  361 

■ of   yellow   fever   from,   370 

• geogra])hical   distribution,  376 

incubation  period,  377 

insects  transmitting,   376. 

leucopenia  in,   377 

seasonal      prevalence      and     general 

habitat  of,   541 

seciuelas   and  complications,   378 

symptomatology,  377 

treatment,   378 

Dermatitis  bullosa  plantaris,  464 
difficulty  in  treatment,  465 

cupoliformis,  difficulty  of  treatment. 


46: 


46c 


exfoliativa,     local     applications     in, 
—  (pityriasis    rubra),     treatment, 


465 
■ macrogyrata,   466 

nodosa  rubra,   treatment,  466 

papillaris  capillitii,  470 

rimosa  of  the  toes,  treatment,  466 

Solaris,  466 

venenata,   classification,   466 

treatment,   466 

vesicular,   505 

Dermatobia  cyaniventris,  larvse  of,  caus- 
ing myiasis,  482 
Dermatophiliasis,  466 
symptoms,   467 

treatment,    467 

Diamond  drill,   Sullivan's,  for  producing 

bore   well,    551 
DiarrhcEa,   chylous   and   lymph,   284 

dysenteric,     infantile,     symptomato- 
logy of,   199 

hill,   setiology,   351 

— — ■  definition,  351 

diagnosis  of  sprue  from,  358 

pathology,   351 

symptoms,   352 

theories  of,  351 

■  treatment,  352 

•  infantile,   treatment  of,   202 

Dibothriocephalus     latus      (human 


worm),  260 

morphology,   266,  261 

produces    severe    anaemia 


fever,  260 
Diet,   articles 

average, 

hard  work. 


tape- 


wit  h 


of,  causing  pain   in   sprue, 
not   engaged    in 


male 


for 

m  pellagra,  336 
in   sprue,  358,  359 

articles  to  be 

in    typhoid     fever 


avoided, 
in     the 


359  . 
tropics, 


222 


in  yellow  fever, 
of  natives,  565 


371 


682 


INDEX 


Diet  of  natives  of  India  and  of  Euro- 
peans contrasted,  in  relation  to  in- 
cidence of  typhoid  fever,  215 

Voit's   standard,    565 

classification,  5C5 

Digestion    in    cerebral    stage    of   African 

trypanosomiasis,    145 
Digitalis,  tincture  of,  in  heat  stroke,  304 
Dionin   in  iritis,  keratitis,   glaucoma  and 

corneal  ulcers,   527 
Diphtheria,  antitoxic  serum  in,  value,  599 
Diplococci,   arrangement,    162 
Diplococus  pneumonia?,  diagnosis  of,  620 

stain,  method  of  finding,  615 

Dipylidium   caninum,    parasite    found    in 

dogs  and  cats,  262 
Diseases,    general,    ocular   manifestations 

of,  522 
Disinfectants,  chemical,   595 

characters  of,  593-4 

in  eye  diseases,   527 


Disinfection,   592 

• chief  means  of,   592 

Distillation  of  water,  558 

Dog,  Schistosoma  japonicum  from,  251 

Dogs    and    cats,    infection    from,    to   man 

of   Dipylidium  caninum,  263 
Double    continued    fever,    low    mortalit\ 

in,  396 

■ •  symptomatology,  396 

Dover's  powder   in   dengue,  378 
Dracontiasis,     geographical     distribution, 

301 

parasite  causing,  301 

pathological  lesions,  304 

prophylaxis  against,  305 

symptomatology,  304 

treatment,   304-5 

Dracunculus    medinensis     (guinea-worm), 
host  and  intermediate  host  of,  301 

■ life-history,  301,  304 

■ morphology,   301,   302,   303 

parasite    causing    dracontiasis, 

301 
Drawer's  ointment,   in  psoriasis,   formula 

^0'''.487 
Drinking  water,  boiling  and  filtration,  in 

prophylaxis  against  dracontiasis,  305 

distillation  from  salt  water,  544 

in    India,    bacterial    standards, 

^.49 
Drinks  in   tropics,   522 
Dropsy,  epidemic,  aetiology,  350 

definition,  350 

diagnosis,  351 

geographical    distribution,   350 

resemblances  to  and  difi"erences 

from  beriberi,  348-9 

symptoms,  350-1 

treatment,  351 


Drug-takers,  Whitmore's  disease  common 

in,  415 
Drugs  in  typhoid  fever  in  the  tropics,  222 

useless  in  hypcrpyrexial  fever,  395 

Dusting   powder,    antiseptic,    application, 

in  filarial  lymphangiectasis,  282 
Dysenteries  (the),  causes,  29 

classification,  29 

history,  27 

of  Ancon  hospital,  classification,  29 

protozoal,  29 


Dxsenterics,  pseudo-dysenteries,  most 
common   in   temperate  climates,   29 

verminous,   29 

Dysentery,  amoebic,  146 

acute,  symptomatology,  36 

chronic,   39 

complication  of  African  try- 
panosomiasis,  146 

■ •  complications  in,  41 

cysts  in  stools  of,  30 

definition,  30 

diagnosis,    42 

geographical  distribution,  30 

histology,    illustrations   of,    33, 


34,  35 


36 


m 


lesions  in  great  intestine, 

— •  liver  abscess  in,  50 

method  of   search  for  cysts 

stools  of  patient  suffering   from,   41 

parasite   of,   30 

pathology,  32 

macroscopic,   34 

section    from    intestine    in   case 

of,  showing  ulcer  of  Harris,  38 

treatment,   42 

—  antitoxic    serum    in,   value,    599 

— ■  bacillary,  29 

acute,  symptomatology  of,    198 

and  amoebic,  diflferentiation  be- 
tween, 42 

— ■  aetiology  of,   196 

— ■  chronic   attacks,    treatment   of, 

symptomatology  of,   199 

complications  of,    199 
definition   of,    196 
diagnosis  of,   200 
geographical     distribution     of. 


202 


196 


358 


of 


pathology  of,    197 

prognosis  of,  200 

sequelae,  200 

spread  of,  factors  in,   540 

symptomatology  of,   198 

treatment  of,  200 

bacilli,    main   types,    ig^ 
bacillus,  diagnosis  of,  619 

types  of,  619 

cause   of,    553 

chronic,    diagnosis    of    sprue    from, 

ciliar    (Balantidium    coli),    parasite 
44 


treatment,  46 


(Lamblia   intestinalis),    treat- 
ment, 46 

mortality   from,   44 

— •  (Tetramitus   mesnili),   47 

— ■  spread    of,    factors   in,    540 
vaccines,  bacterial,  602 


Dysidrosis  exfoliativa,   467 


Earth,  bacteriology  of,  646 
Echinococcus    granulosus    causing    cystic 
form  of  hydatid  disease,  267 

dangers  of,  to  man,  268 

geographical  distribution,   267 

life-cycle,  267 

morphology,  267 

pathogenicity,  268 


INDEX 


683 


Echinococcus  multilocularis,  geographi- 
cal distribution,  268 

morphology,  268 

pathogenicity,  26g 

producing  multilocular  form  of 

hydatid  disease,  268 

Eclipse  blindness,   509 

Eczema,  definition,  467 

symptomatology,  467 

treatment,  468 

varieties,  468 

Egypt,  percentage  of  population  infected 
with  Schistosoma  haematobium,  242 

Ehrlich's  side-chain  theory  of  protection 
afforded  by  sera  and  vaccines,  601 

Elapinse,  423,  428,  431 

in  America,  434 

in  Australia,  433 

Elapine    venom    (snake-bite),    symptoms, 

442 
Elaps  fulvius  (harlequin  or  coral  snake), 

427 
Elastorrhexis  or  pseudo-exanthoma,  502 
Electrical   methods    of    sterilizing   Avater, 

Electricity  and  iodides  in  dengue,  379 
Electrolysis  in   hirsuties,   471 
Elephantiasis,  284 

arabum,  reasons  why  due  to  Filaria 

bancrofti,  287,  288 

causes  of,  279,  280 

■ of  arm,  293 

■ of  breast,  291,  293 

of  legs,  284-287 

■ after  operation  286 

■ before  operation,  285 

symptomatology,   284-287,    293 

treatment,    286 

of  localized  areas,  293 

of  prepuce  and  legs,  288 

of  scalp,  293 

of  sci^otum,  289,  290 

complications  following  opera- 


tion, 292 


291 


operation  for  removal  of  mass, 

symptomatology,    290 
treatment,  291 

of  vulva,  292 

post-mortem  findings,  280 

Elephantoid  tumour  of  buttock,  287 
Emaciation  in  cerebral  stage  of  African 

trypanosomiasis,    14:5 
Emetine  in  amoebic  dysentery,  43 

in     ciliar     dysentery      (Balantidiam 

coli),  46 

in  liver  abscess,  54 

in  sprue,  360 


Endemic  diseases,  543  , 

Endo-ectothrix  tinea,  489 
Endothrix  tinea,  489 

histolytica    in  tissues,  37 

tetragena  of  amoebic  dysentery,  life- 
history,  31 


binary  fission,  31 


—  reproduction  by 

reproduction       by 

—    reproduction        by 

spore  formation,  31 
parasite    of   amoebic   dysenterv. 


gemmation,  31 


Enteritidis  group  of  bacilli,  diagnosis  of, 

618 
Eosin-azur  for  staining  malarial  parasite 

in  blood,  608 

use  of,  as  stain,  604 

Eosinophiles,  diseases  during  which  in- 
creased, 605 

percentage   in   normal   blood    count, 

605 

Epidemic  diseases,  sporadic,  543 
Epileptiform,   a   complication   of   African 

trypanosomiasis,    146 
Epinys  norvegicus   (Norway  rat),  plague 

in,   170 

rattus  (brown  rat),  plague  in,  170 

Epithelial   tumours,   benign,   495 

malignant,  495 

Epithelioma  of  cheek,  fungating  papillo- 
matous, 500 

Epitheliosis    desquamativa    (Samoan    eye 

disease),  516 
Ergotism,  453 

causes  of,  572 

Erysipelas,  treatment,  468 
Erythasma,  468 

Erythema  of  verruca  peruviana,  364 

solare,  468 

Erythematous  eruptions  in  African  try- 
panosomiasis,  140 

Erythropsia,  509 

Espundia,  68,  504.  See  also  Leish- 
maniasis,  naso-oral  and  oro-pharyn- 
geal 

Eucalyptus  treatment  of  ankylostomiasis, 

3ig 
Europe,   cholera  epidemics,  203-4 
Europeans  first  entering  Tropics,  liability 

to  typhoid   fever,   215 

in  India,  diet  of,  in  relation  to  in- 
cidence of  typhoid  fever,  215 

pathological  eft'ects  of  hot  climates 

on,  538 

physiological  eft'ects  of  hot  climates 


on,   537 
Excreta,  chemical  method  in  disposal  of, 
588,  590 

disposal  of,  590 

Exhaustion  (pabulum)  theory  of  protec- 
tion aftorded  by  sera  and  vaccines,  600 

Eye  conditions,  local,  resulting  in  blind- 
ness, 511 

contusions    and    concussion    injuries 

of,  509 

diseases   of,    507,    508 

local,  509 

native  treatment  of,  529 

remedies,    various,    in,    529 

stimulating       and       astringent 


remedies  in,  526 

treatment,   526 


142 


526 


29 


lesions  in  African  tr>-panosomiasis, 
rest  in  treatment  of  &\e  diseases, 
traumatisms  affecting,   509 


F.ECAL  carriers  of  typhoid  fever,  214 
contamination    of    waters    in    India, 

excessive,  645 
F?eces    and    water,    bacteriology    during 

monsoon  weather,  O46 


684 


INDEX 


F.TCcs   examination    for   eggs   of   Ascaris 
lumbricoides,  31 1 

diagnosis  of  diseases  from,  632 

• macroscopic,  632 

microscopic,  634 

errors  in,   6315 

helminth    ova    in,    preservation    of. 


323 


648 


human  and  animal,  bacteriology  of, 

in  sprue,  357 

paleness  of,  causes,  358 

Fat,    deficient,    in    aetiology    of    beriberi. 


339 

estimation  of,  in  faeces,  process,  633 

Fats,  food  value  of,  563 
Favism,  aetiology,  389 

definition,   389 

distribution,  389 

symptomatology,   389 

treatment,  389 

Febrile    or    glandular    stage    in    African 

trypanosomiasis,   140 
Fever,  daily,  in  cerebral  stage  of  African 

trypanosomiasis,    145 

in  African  trypanosomiasis,   140 

Fibrin  ferment  in  snake  venom,  441 
Fibrolipoma,  pendulous,  of  back  of  neck, 

407  ,  ■        •  r 

Fibrolysin    injections   in   elephantiasis   of 

legs,  286 
Fibroma  molluscum,  502 
multiple,  499 

of  neck,   495 

pendulum,    502 


Fibromatous    condition    of    skin,    curious 

example  of,  496 
Field  rat,  reservoir  host  for  spirochsetes, 

Filaria  bancrofti,  adult,  273 

carriers  of,  278 

cause  of  elephantiasis  arabum, 

reasons  explained,  287,  288 

embryo,  274.     See  also  Micro- 


filaria  nocturna 

life-history,  273 

morphology,  272 

ovum,  273 


carriers  of,   294 

infections     associated     with     double 

conjunctivitis,    discharging   chyle,   294 

Filariasis,  clinical  manifestations,  279 

geographical  distribution,  278 

historical  notes,  271 

— ; —  pathology,  278,  279 
Filaridsc,   diseases  caused  by,  271 
Filtration  of  water,   558,   559 
Finkler-Prior   spirillum,   621 
Fish   venom,   effects  of,  447 

high   mortality   from,   448 

■ symptoms,  448 

treatment,   448 

Fishes,  venomous  and  poisonous,  447 

which    poison    after    their    consump- 


tion as  food,  448 


symptoms,  448 


by      sjnnes,      mortality      from 

wounds  of,  448 

pain    severe   after    wound 


from,  448 
Five-day   fever    (\'olhynia    fever),   398 


Flea,    species  infesting  rats   and   convey- 
ing plague,   171 
Fleas,  alimentary  tract  of,   178 

carriers  of  plague  bacillus,  177 

destruction  of,   179 

external  appearance,  177 

families   of,    179 

larvas  of,   179 

reproduction,  method  of,   178 

Fleming's    modification    of    Wassermann 

reaction,  6io,  611 
Flexner  type  of  dysentery  bacillus,  619 
Flcxner's      process     of     preparing     anti- 
dysenteric  serum,  201 
Flies  and  disease,  223 

danger    of,    to    health,    manner    of 

infection  by,   223 

transmission  of  cholera  by,  206 

■ ways  in  which  dangerous  to  health, 


preservative   test   for  food, 


223 
Fluorides,   as 

579 
Fly,  biting,   in  aetiology  of  pellagra,  332 

carriers  of  typhoid  fever,  214 

Folliculitis  decalvans,   471 
treatment,    471 


Fomites,  transmission  of  cholera  by,  20*5 
Food  adjuncts,   563 

deficiency    in    aetiology    of    beriberi, 

338-9 
in  aetiology  of  pellagra,  329-30 

morbid  conditions   caused  by,  571 

poisoning    in    setiology    of    beriberi, 


338 
Foods,    adulteration   of,    569 

calorie  value  of,  565 

essential  consituents  of, 


562 


tinned,  dangers  from,  575 

Foot,     amputation     of,     for     perforating 

ulcer  in  lepers,    185 

Fordyce's  disease,   477 

Foreign  bodies  in  eye,   509 

Formaldehyde,  as  preservative  test  for 
food,  577 

Formalin  in  sjiirit,  a])plication  in  tricho- 
mycosis, 495 

solutions  of,  in  treatment  of  African 

trypanosomiasis,    149 

Formic     aldehyde      for     disinfection     of 

houses,   595 
Framboesia  tropica  (yaws),  diagnosis,  26 

■ causation,   22 

•  contagious  disease  due  to  Tre- 
ponema pertenuis,  21 

• histopathology,   22 

• incubation,  23 

infection   of   by   direct  contact, 


25 

primary  stage,  23 

prodromata,  23 

■ secondary  stage,  23 

■ symptomatology,  23 

• tertiary  stage,  24 

three  stages  in,  23 

treatment,    26 

Fungi,  eye  diseases,  local,  due  to,   511 

in  fEtiology  of  pellagra,  331 

ocular  aspergillosis  due  to,   511 

blastomycosis  due  to,   511 

gonosporosis   due   to,    511 

moniliasis   due   to,   511 


INDEX 


685 


Fungi,   ocular   nocardiasis   due   to,    511 

sporotrichosis  due   to,   511 

tinea  due  to,  511 

producing   madura  foot,    478 

Funiculitis,  endemic,  definition,  407 

geographical   distribution,   407 

pathology,    407 

symptomatology,  408 

treatment,  408 

must  be  surgical,  408 


Galvl  in  framboesia  tropica,  27 
in    treatment    of     African 


trypano- 


somiasis,   148 


Gangosa,   definition,   404 

diagnosis,  405 

distribution,  404 

late  manifestation   of  yaws,   25 

(rhino-pharyngitis    mutilans),    404 

symptomatology,   404 

treatment,  405 

Gastro-enteritis,   ha^morrhagic   febrile,   of 

children,  prognosis  grave,  403 
Gelatin,  nutrient,  preparation  of,  622 

l)late  cultures,  623 

Gemmation,  asexual  method  of  reproduc- 
tion in  protozoa,  3 
Genosporosis,  ocular,  due  to  fungi,   511 
Ghee,   568 
Glanders,  504 

Glanders  bacillus,  see  Bacillus  mallei 
Glossina  bocayei,    151 

fusca,   151 

longipalpis,   151 

longipennis,    151 

morsitans,    151 

carriers      of      Trypanosoma 


pecorum,   135 

food  of,    152 

habits  of,    152 

reproduction  of,    15: 

—  pallicera,   151 

—  pallidipes,   151 

—  palpalis,   151 

food  of,   152 

habits  of,    153 

reproduction   of,    15: 


of 


tachinoides,   151 

Glossinae,  notes  on,    15 1-3 
Glossitis  areata  exfoliativa,  477 
Glottis,      oedema      of,      complication 

African  trypanosomiasis,    146 
Glucose    and    lactose    broth,    preparation 

of,  622 

peptone  Avaters,  preparation  of, 

622 
Glycerine  of  tannin  in  trachoma,   515 
Gnathostoma  spinigerum  rarely  found  in 

man,  271 
Goitre   in  the   Tropics,   410 
Gonococcus,   diagnosis  of,  620 
Goode,     Norman,     method    of     cleansing 

washing  water,    560,    561 
Goundou,   definition,  411 
■  geographical   distribution,  411 

pathology,  411 

symptomatology,   412 

treatment,  412 

Grain  itch,  469 

treatment,  formula  for,  469 


Gram-negative  and  Gram-positive  organ- 
isms, important  differentiations  in 
staining,   614 

Granules,  metachromatic,  volutine,  and 
metaplasmic,  in  protozoa,  3 

Granuloma  inguinale,  treatment,  469 

ulcerating,   503,  505 

Green,  protective  colour  in  prevention  of 
sunstroke,  392 

Grooved   tongue,   477 

Ground-nut,  common  (Arachis  hypogoea), 
nutritive  value  of,  564 

Ground  squirrel,  spread  of  plague  by,  171 

Guinea-worm,  see  Dracnncuhis  medineti- 
sis 

Gynocardic  acid  in   leprosy,    188 


H^MADIPSA    in    a-tiology    of    hirudiniasis, 

324 
Hsemato-chyluria,   283 

in  filariasis,  279 

lymphuria,  283 


Hsematoxylin     and     eosin      for     staining 
malarial  parasites  in  blood,  608 

use  of,  as  stain,  604 

Haemoglobin,    estimation    of,    in    Tropics, 

607 

reduced,    demonstration    by   spectro- 
scope, 612,  613 

Haemoglobinuric        (blackwater)        fever, 
aetiology,  381 

■ definition,   380 

• •  distribution,   380 

pathology,    384 

post-mortem  appearances,  386 

■ •  symptomiatology,  387 

theories    relating   to,   381 

treatment,    388 


Hsemolysins  in  snake  venom,  440 
Haemolysis   due   to   parasites  of   malaria, 

74 
Haemoptysis,     endemic,     see     Paragono- 

viiasis 
Haemorrhage   in   yellow   fever,   treatment, 

371 
Haemorrhages,     rectal,     causing     sudden 

death    in     spirochaetosis     ictero-haemor- 

rhagica,  18 
Hasmorrhagin  in  snake  venom,  441 
Haffkine's     prophylaxis     against     plague, 

175,    176 

vaccine    in    proph\laxis    of    plague, 

176 

Hair  affections,  469 

colour  of,  changes  in,  causes  of,  470 

poor   development  of,  in   natives   of 

Tropics,  458 

Hansen's  Bacillus   leprae,    180 
Hardness,     total,     of    water,     method    of 
estimating,  654 

permanent,     of     water,     method     of 

estimating,  654 

temporary,     of     water,     method     of 


estimating,  654 
Harris,     ulcer     of,     section     of     intestine 
showing  in    case   of   amoebic   dvsenterv, 

Hay     fever,     tropical      (rhinitis     plasties 
vasomotoria),    404 


686 


INDEX 


Hay  fever,  tropical,  treatment,  404 
Health,     maintenance     of,     in     Tropics, 

general  rules  for,  541 
Heart    failure   cause  of   sudden    death   in 

Asiatic   relapsing    fever,    15 

treatment  of,  in  typhus,  380 

Heat  as  means  of  disinfection,  593 

exhaustion,    530 

stroke    (sunstroke),    aetiology,    391 

and    heat    syncope,    differences 

between,  390 

causation,  theories  as  to,  391 

definition,  391 

diagnosis,  394 

(direct),   391 

■ (indirect),   393 

. mortality,  393 

prophylaxis  against,  392 

results  of,  392 

• symptomatology,  392 

treatment,  394 


syncope,  389 

aetiology,  390 

definition,   390 

• symptomatology,   390 

treatment,    391 

Heating  in  sterilization  of  water,   ^58 
Helminth  ova  in   faeces,   preservation  of, 

323.       .     . 
Helminthiasis,    complication    of    African 

trypanosomiasis,    146 
Helminths,  diseases  due  to,  226 

distribution,  228 

factors  controlling,   228 

grouping  of,  231 

mode   of   infection   by,   320 

■ nomenclature,   230 

pathogenic  action,   variation   of,   229 

preservation     and     examination     of. 


^21-2 

. toxic,  449 

Herpetomonas,  5 

Hindu  water-carriers,  vessels  used  by,  552 

Hirsuties,   471 

treatment,    471 

Hirudiniasis,  aetiology,  324 

definition,   323 

• symptomatologx',    324 

treatment,  324 

Histoplasma  capsulatum,  6 

date  of  discovery,  6 

diseases  caused  by,  6 

habitat,  6 

Horny  growth  from  cheek,   504 
Horse,      preparation      of      antitoxic      sera 
from,    599 

serum,      immune      in      spirochtetosis 

icterohaemorrhagica,   19 

Horsley,  Sir  Victor,  death  of,  from  heat 
stroke,  393 

Hot-air  sterilizer,  622 

Hot  climates,  pathological  effects  on 
Europeans,   538 

,  physiological  effects  on  Euro- 
peans,  537 

House-fly  (Musca  domestica),  enemies  of, 
225 

habits,  &c.,  of,  224 

how  man  is  infected  by,  225 

ways  of  suppression  of,  225 


Houses,  disinfection  of,  fumigation  as 
means  of,  595 

suitable,     construction     in     tropical 

districts,  535,  536 

Hughes,  Basil,  method  of  cleansing 
washing  water,  560,  561 

Humerus,    chondrosarcoma  of,   498 

Hydatid  disease,  cystic  form  of,  due  to 
infection  by  Echinococcus  granulosus, 
267 

multilocular  form  of,  pro- 
duced by  Echinococcus  multilocularis, 
268 

Hydrocele,  see  Orchitis  and  hydrocele , 
filarial 

Hydrochloric  acid  in  sprue,  360 

Hydrochloride  (emetine)  in  amoebic  dys- 
entery, 42 

Hydrophinae,  425 

■ genera  of,   426 

in  Australia,  433 

Hydrophine    venom     (snake    bite),     sym- 
ptoms, 442 
Hydrophis  coronatus,   photograph  of,  424 
Hygiene,    constitutional,    535 

relation  to  tropical  diseases,  539 

Hymenolepis    diminuta    common    to    rats 

and  mice,  263 

nana,  dwarf  tapeworm  of  man,  263 

■  intestinal      irritation      and 

anaemia  resulting  from  infection  by,  in 
children,    263 
Hyperaesthesia,  deep,  in  African  trypano- 
somiasis, 142 

in  cerebral  stage  of  African  trypano- 
somiasis,   145 

Hyperkeratosis,  495 

Hyperpyrexial    fever,    high    mortality    in, 

396 
Hyphomycetes,  divisions  of,    630 

ICHTHYOL  in  acrodermatitis  vesiculosis 
tropica,  460 

in  climatic  bubo,   411 

in  filarial    lymphangitis,    281 

ointment,     application    to     Calabar 

swellings,  300 

Ichthyosis   glossae,   477 

hystrix,   473 

treatment,   473 

simplex,  473 


Immunity,   acquired,   definition,    598 

active,   16:5 

•  natural,   165 

definition,   598 

passive,    165 

theories  of,   163 

to  diseases  afforded  by  vaccines  and 


sera,  601 
Impetigo,  473 

treatment,   473 

Incubation    of    trypanosomiasis,    African 

incubation,    139 
India,   bacterial   standards    for   purity    of 

drinking  water   in,  649 

deaths     from     snake    bite    annually 

in,   419 

diet  of  natives  and   Europeans  con- 


trasted    in     relation     to     incidence     of 
typhoid  fever,  215 


IXDEX 


687 


India,    standard    for    bacteriological    ex- 
amination of  water  in,  645,   646 

waters  of,    faecal   contamination   ev- 

cessive,  6415 

Infant  feeding  in   Tropics,   580 

table   for,    580 

foods,   prepared,   dangers  of,   581 


Infants,   biliary  cirrhosis   in,   409 
Infective  diseases,  common,  some  prophy- 
lactic measures  for,   598 
Infectivity  theory  in  aetiology  of  pellagra, 

331 
Influenza,  diagnosis  of  phlebotomus  fever 

from,  361 
Injections,   local,  in   snake  bite,  446 

preservative,     for     preservation     of 

meat,  575 
Insecticides,   ^94 
Insects,  eye  diseases  (local),  due  to,  510 

how  infected  with  animal  parasites, 

7 

Intertrigo  saccharoraycetica,   473 

■ treatment,   473 

Intestinal  disorders,    dietetic    causes    of, 

symptoms  and   lesions  of  ascariasis. 

3". 
Intestine,    elimination    of    toxins    b>',    in 

yellow  fever,  371 

great,    lesions   of   amcebic   dysentery 

^^'  .3*^. 

irrigation    of,    in    intestinal    schisto- 


somiasis,  256 

with    sodium    hypochloride    or 

tannic  acid  in  schistosomiasis,  256 

sections    from,    in    case    of    amoebic 


dysenterv,     showing    ulcer    of     Harris, 

38 
Intestines,    post-mortem    appearances    of, 

in     schistosomiasis     infected     with     S. 

japonicum,   252,  253 
Iodides    in    granuloma    inguinale,   469 

in  sporotrichosis,  488 

Iodine,  tincture  of,  application  in  dif- 
ferent forms  of  tinea   (ringworm),   490, 

491,   493,   494  . 
Iodoform   injections  in   lein'osy,    189 

suppositories  in  oxyuriasis,  313 

Ipecacuanha   in   ciliar  dysentery   (Balan- 

tidium  coli),  46 

in   amoebic  dysentery,   43 

in  hepatitis  in  liver  abscess,   55 

in   sprue,   360 

Irido-cyclitis  in  cerebral  stage  of  African 
trypanosomiasis,    146 

Iritis,  complication  of  African  trypano- 
somiasis,   146 

Iron   in   afebrile   splenomegaly,   417 

in  water,  method  of  estimating,  655 

water  pipes,  diminution  in  dia- 
meter, 552 

Irrigation,   regulations  regarding,   in   the 

Soudan,   534 
Ixodidse    (tick),    spirochsetes    of,    African 

tick  fever  transmitted  by,    19 


Jails,  _   planning     and     construction,     in 

tropical    districts,    536 
Japanese  river  fever,  aetiology,  394 


Japanese  river  fever  and  spotted  fever  of 
Rockv    Mountains,    similarity   between, 

distribution,   394 

— —  ■ (Tsutsugamushi    disease), 

definition,  394 

mortality,   395 

• symptomatology,  395 

treatment,  395 

Jaundice  not  due  to  increased  formation 
of  bile  in  spirochaetosis  icterohaemor- 
rhagica,   18 

Jaw,  lower,  cystic  bone,  sarcoma  (mye- 
loid ?)   of,   499 

sarcoma  of    (?  myeloid),    497 

Jelly  fish,  sting  from,  symptoms,  449 

venomous,   448 

Jiggers,  complication  of  African  trypano- 
somiasis,  146 


Kala-azar,  aetiology,   56 
and  oriental  sore,  differentiation  be- 
tween,  66-68 

blood   in,   60 

• definition,    ,6 

diagnosis.   60 

geographical   distribution,   56 

history,    56 

incubation,    58 

infantile,  aetiology,  62 

antimony,    63 

— -  complications,  62 

definition,    61 

■  distribution,   61 

symptomatology,  62 

synonyms,    61 

morbid   anatomy,   60 

prognosis,   60 

symptoms,    59 

termination,    59 

transmission,   mode   of,   8 

treatment,  61 

prescription  in,  61 

see  also  Pseudo-kala-azar 

Kaposi's     disease     (Xerodermia     pigmen- 
tosum), 474 

Kcrandal's     cure     for     African     trypano- 
somiasis,   150 

sign  in  African  trypanosomiasis,   142 


Keratoma  plantare  sulcatum,  474 

■ treatment,  474 

Keratomalacia,    510 

Keratosis   pilaris,    treatment,   473 

(xerodermia),   473 

Khartoum,     bacteriological      examination 

of  river   and   well  water  in,   642,   643 
Kidney,     most     venom     excreted     by,     in 

snake   bite,   445 
Kidneys,     elimination     of     toxins    by,     in 

yellow^   fever,   371 

in  blackwater  fever,  386 

Klcbs-Loffler      bacillus.       See      Bacillus 

diphtheri(s 
Klein's    protective     inoculation     prepared 

from     organs     of     animals      dead     of 

plague,    177 

advantages,    177 

Knee,  acute  synovitis  of,  associated  with 

filaria    infection,    294 


688 


INDEX 


Koch's   comma  bacillus,   62 1 

cause  of  cholera,   205 

Kraurosis   vulvic,    477 
Krcotoxismus,  45 ^ 

treatment,  45s 

Laboratory,  hints  for  work  in,  603 

Lacertilia,   423 

Lactose   fermenting   organisms   in    water, 

test  for,  643 
Lake  water,   bacteriology  of,  648 
Lakes,  purity  of,    547 

water  supplies  from,  547 

Lamblia  intestinalis,    5,   47 

parasite  of  ciliar  dysentery,  46 

Lamus    megistus   as    agent    in    spreading 

South   American    trypanosomiasis,    154 
Lanoline,       amplication       in       ichthyosis 

hystrix,  473 

ointment    in     filarial     lymphangitis, 

281 

Laryngitis,    complication   of  African    try- 
panosomiasis,   146 
Latah,  geographical  distribution,  406 

symptomatology,   406,   407 

Lathyrismus,   453 

causes   of,    572 

symptoms,   453,   454 

treatment,   454 

when  endemic  and   when   epidemic, 

453 

Latrines,    Chinese,    587 

European,   588 

for    troops    in    the    field,    chemical 

method,    588 

in  tropics,    1585 

Indian,  588 

native,   585 

separation  system  in,  587,   588 


river,   practice  of,  insanitary,   586 

Lead    and    opium    lotion    in    filarial    lym- 
phangitis, 281 

in     filarial     orchitis     and 

hydrocele,   281 

dissolution     from     water     pipes     by 


peaty  water,  5:52 
— in  water,  method  of  estimating,  655 
lotion,  application  in  climatic  bubo. 


411 
Leeches,   land  and  water,   in  aetiology  of 

Hirudiniasis,   324 
Legs,  elephantiasis  of,  284-287,  293 
Leishman-Donovan  parasite  of  kala-azar, 

r     5.7 

Leishmania,   6 
Leishmaniases,   55 
Leishmaniasis,  canine,  68 

acute  and  chronic,  69 

dermal    (oriental   sore),  63 

aetiology,  63 

definition,   63 

diagnosis,   65 

points   to   be   noted   in,   65 


distribution,  63 
histopathology,   63 
prognosis,   65 
symptomatology,   64 
treatment,    66 


naso-oral  and  oro-pharyngeal,  68 

symptoms,  68 

treatment,  68 


Leishman's   stain,   604 

for   staining   malarial    parasite 

in  blood,   608 
Leproline   in    leprosy,    i8g 
Leprosy,  Eesthctic,  macular  in,   187 

deformities  in,    184 

variety,   186 

antitoxic   serum   in,    599 

bacillus,    180 

definition,    179 

geographical  distribution,    180 

history,    179 

how  spread,   181 

little    influenced    by     climatic    and 


tropical    conditions,    540 

—  mixed   variety,    188 

—  nodular,  in  Hindoo  woman,   183 

—  pathology,    181 

—  post-mortem  appearances,  182 

—  prognosis,   188 

—  symptomatology,    182-3 

—  treatment,    188 
tubercular  variety,    184,    186 


Leptothrix,  471 

treatment,  471 

Leucocytes  in   lymphatic  leukaemia,   606 

percentage  in    normal   blood   count, 

605 

total,       diseases       during      which 

diminished,   605 

Leucocytosis   in   blackwater  fever,   387 

in   verruga  peruviana,  364  ' 

Leucocytozoida?,    5 

Leucoderma,  474 

treatment,  474 

Leucolysins  in  snake  venom,  441 
Leucopenia  in   dengue,   3,77 

in  sprue,  357    . 

Leukaemia,   lymphatic,   leucocytes  in,   606 

spleno-meclullary,      myelocytes      in, 

606 

Leukoplakia  of   tongue,   477 

varieties,  477 

Lice,  venom  of,  451 
Lichen  convex,   474 

treatment,   474 

planus,   4715 

treatment,   475 

external,  formula  for,  475 

■ formula   for,   475 

Ligature  in  snake  bite,  445 
Lightning   causing  blindness,    510 
Lime,  chloride  of,  use  in  purification  of 
water,    5  55 

chlorinated,       for      purification      of 

^vater,   5  56 

Limnatis    in    a!tiology    of     Hirudiniasis, 

.324 
Li]5omatosis,  nodular,  483 
Licj[uor  arsenicalis  in  pellagra,  336 

plumbi      a])plication       to      Calabar 

swellings,  300 

Liver  abscess,  causation,   48 

diagnosis,   52 

high  mortality,   53 

in  amoebic  dysentery,  50 

incidence,  48 

—  operation   for,    after-treatment. 


54 


method   of,   53 


pathology,    50 


INDEX 


689 


Liver  abscess,  position,  48 

spontaneous  rupture  of,  52 

symptomatology,  51 

termination,  52 

■ treatment,    53 

—  varieties,   48 

abscesses  of,  multiple,   ania^bic,   49 

condition    in   yellow    fever,    367 

in  blackwater  fever,  386 

microscopical  appearance  in  African 

trypanosomiasis,    139 

post-mortem      appearances      of,      in 

schistosomiasis  infected  with  S.  japoni- 
cum,  252 

tropical,   414 

parasite      of      dermal       leish- 


maniasis, 63 

sym]5tomatology,   414 

treatment,   55,   414 

prescription   for,  414 

Lizards,  venomous,  4^3 
Loa  loa,  carrier  of,  298 
causative     parasite    of     loasis, 

296 

habits,  298 

• illustrations   of,   296,  297,   298 

life-history,   298 

morphology,   296,   297,   298 

Loasis,  causative  parasite,  296 

definition,    295 

geographical  distribution,  295 

symptomatology,  299 

treatment,   299 

Lolismus,  454 

Loos  hypothesis  of  schistosomiasis,  con- 
clusions as  to  prevention  and  treatment 
based  on,  249-250 

theory  of,    relating    to    S.    mansoni. 

Lotions,  application  to  tropical  ulcera- 
tions,  505 

Low  intermittent  non-malarial  fever, 
long    course  of,    396 

symptomatology,  396 

Lungs,  microscopical  appearance  in 
African  trypanosomiasis,   139 

Lupus  erythematosus,  differentiation  from 
lupus  vulgaris,   475 

treatment,  476 

Lustig's  and  Galeotti's  serum  in  prophy- 
laxis of  plague,  176 

Lymphangiectasis,  filarial,  definition,  281 

symptomatology-,  281 

treatment,  282 

Lymphangiomata,    502 

Lymphangitis,  filarial,   definition,   280 

post-mortem  findings,  280 

symptomatology,   281 

treatment,   281 

Lymphatic   glands,   fibrosis,    in    filariasis. 


279 


142 


in      African      trypanosomiasis, 
in    cerebral    stage    of    African 


trypanosomiasis,    145 
microscopical 


appearance     m 


African  tryjianosomiasis,  139 

varicose,  282 

treatment,    2S2 

—  tissue,     bacilli     of     typhoid 

chiefly  invading,  216 


fever 


Lymphocele,    284 

Lymphoc\tes,  diseases  in  which  in- 
creased, 605 

percentage    in    norma i    blood   count,, 

605 

Lymphoderma   perniciosum,   502 

Lymjihuria.  See  Chyluria  and  lyvi- 
-phnria 

Lysol   as   disinfectant,    594 


Macgregor,    Sir    William,    plan  of    pro- 
tected well  suggested  by,   550 
Maculae   in  aesthetic  leprosx",    187 
Macular  fever  of  Tunisia,  definition,  397 

symptomatology,   397 

Mahommedan  water-carriers,  infection  of 

water  by,    551 
Maiche   automatic   sterilizer,    558 
Maignen's   process    for    softening    water. 

Maize    theory    in    a?tiology    of    pellagra^ 

330-1 
Malaria,   69 

aetiology,   exciting  causes,   71,   72 

predisposing  causes,   ~o 

carriers  of,  69 

■ complication     of     African     trypano- 
somiasis,   146 
cure  of,   possible   future  method,  74 

definition,  69 

diagnosis      of      phlebotomus      fever 


from,   361 

eradication    of,    l)y    ciuinine    in    pre- 


vention of  h?emoglobinuria   fever,  384 

•  history   of,    69,    70 

parasites  of,  69,  71,   72 

behaviour   in   blood,    72,    73 

ha;molytic  action,  74 

infection   by,    mode   of,   8 

intracorporeal  or  human  cycle,. 


74 


life-cycle,  75 
life-history,   72,   73 


—  pernicious      manifestations     of,      in- 
brain  and  pancreas,    74 

—  preceding      t\'phoid      fever     in      the- 


tropics,   217 
—  prevalence  of,  conditions  favouring,. 


540 

—  recurrent    attacks    of,    followed    by 
blackwater   fever,   387 

subtertian     and     blackwater     fever,. 


relation  between,  384 
diagnosis  of  yellow  fever  from,. 


370 


symptoms,    general,   69 


Malarial   fever,   factors   necessary  for  an 

attack   of,    72 
large    mononuclears    increased 

during,   605 

phases  of  related  to  phases  of 


life-cycle  of  parasite,  72 

ciuartan,   parasite   causing,    "jz 

—  '_ tertian,   parasite   causing,   73 

infection,  active,  theory  that  ha2mo- 


globinuric  fever  is  manifestation  of,  381 
previous     theory     that     haemo- 

globinuric    fever   is    condition    brought 

about  by,  383 
—  pigment,  constituents  of,  628 


690 


INDEX 


Malarial  pigment,  where  it  is  and  how  to 

look  for  it,  628 
pigments,    manner    of    showing    in 

laboratory   work,   629 
Male,  adult,  not  engaged  in  hard  work, 

average  diet   for,    564 

fern  in  hymenolepis  nana,  263 

in     intestinal     schistosomiasis, 


256 


in  schistosomiasis,  248,  256 
in  tapeworms,   269 


Malignant  connective  tissue  tumours,  502 
Malta    fever,    diagnosis    of    phlebotomus 
fever   from,   361 

— — ■  see  also  Undulaiit  fever 

Manchineel  tree  fruit,  poisoning  by,  454 
Manchuria,    pneumonic    plague    in,    how 

started,    171 

Mania  in  cerebral  stage  of  African  try- 
panosomiasis,   145 

Manson,  Sir  Patrick,  reasons  for  elephan- 
tiasis arabum  being  due  to  Filariaban- 
crofti,  287,  288 

Massage   in   dengue,   379 

in  elephantiasis  of  legs,  286 

of    scrotum,    291 

Mast    cells,    605 

staining   of,   605 

Mastigophora    (flagellata),  4 
Measles  in  tropical  countries,  401 
Meat,     decomposed,     results     from     con- 
sumption of,   572 

diet   in    sprue,   359 

extracts,   limited  use   of,    567 

stimulating  but  not  nutritious, 


566 


frozen,  means  of  testing,  573 
inspection  and  high  cooking  in,  pro- 


phylaxis  against   trichiniasis,   309 
—  preservation  of,    574 

methods,   S/S 

native  method,   575 


preserved,  means  of  testing,  573 

Meats,    examination   of,   572 

Medical  ofticer,   control  of  water  by,   553 

Memory,    loss    of,     in    tropical    regions, 

539 

Men,  women  and  children,  food  necessary 
for,    compared,    564 

Meningitis,  cerebro-spinal,  a  complica- 
tion of  African  tryijanosomiasis,   146 

sunstroke,  a  form  of,  393 

Meningococcus,  diagnosis  of,  620 
Menstruation  in  cerebral  stage  of  African 

trypanosomiasis,    145 
Mercurial  ointment  in  oxyuriasis,  313 
Mercury,    atoxylate    of,    in    treatment   of 

African  trypanosomiasis,   148 

solutions  of,  in  treatment  of  African 

trypanosomiasis,    149 

Metals,  poisonous,  in  water,  detection 
and    estimation    of,    655 

Metchnikoff,   jihagocytic  theory  of,  600 

Methremoglobin,  demonstration  by  spec- 
troscope, 613 

Methylene  blue  in  ciliar  dysentery  (Balan- 
tidium  coli),   46 

^ —  Loeffler's,  use  of,  as  stain,  604 

Mucorinal,   diagnosis,   630 

Micrococcus  melitensis,  cause  of  undulant 
fever,  190-1 


Micrococcus  melitensis,  diagnosis  of,  620 
Microfilaria    demarquayi,    film    prepara- 
tion,  276 
diagnosis  of,  points  of  value  in,  277 

infection        of       man,       dangerous 

elements  in,  276 

loa,  film  preparation,  275 

■ nocturna,  274 

habits  in  man,  274 

habits    in    mosquito,    275 

perstans,    film   preparation,   275 

various    species    of,    differentiation, 

277 

Microfilarije,  examination  of  fresh  blood 

for,  610 
Micro-organisms,  diagnosis  of,  615 

examination   of,  613 

staining  of,    613 

Microsporon  audouini  (ringworm),  631 

A/Iicrosporons,   489 

and     trichopytons, 

tween,  489 
Milk,    adulteration    of, 

rence   in    the    tropics, 
buffaloes,  568 

condensed,   568 

decomposed,  results  from  consump- 
tion of,   572 

diet   in   si^ruc,   358 

dried,    568 

food  value  of,  567 

goats',    568 

— —  heating  of,   567 

homogenized,   568 

infected,    results   from   consumption 


differences     be- 


common 
569 


occur- 


of 


)   :>/■ 


manipulations    of, 
skimmed,   568 

■ dried,  568 

sour   Bulgarian, 


D/^ 


use   of,    for    thera- 


peutic purposes,  631 

transmission  of,  cholera  by,  206 


of 


Mineral  acidosis,    theory   in   aetiology   of 

pellagra,    332-3 
or    chemical    constituents    of   water, 

ill-effects  of,    553 

•  waters,    584 

Molasses  and  botassa  in  milk,   tests  for, 

569 
Moles,   epithelial,  49, 
Molluscs    essential     for    transmission 

bilharzia,    543 
Molluscum   contagiosum,   495 
Mongolian   spots,  476 
Alonilia  vaccines  in  sprue,  360 
Moniliasis,    ocular,   due  to    fungi. 
Monilethrix,    471 
Mononuclears,     large 

malarial  fever,  G05 
l^ercentagc 


:ii 


increased 
normal 


in 


during 

l)lood 
count,  C05 

Monsoon  weather,  bacteriology  of  water 
and   fasces  during,  646 

Montana,  spotted  fever  of  Rocky  Moun- 
tains in,  mortality  and  prophylaxis 
against,  376 

Morphia  for  relief  in  griping  in  amoebic 
dysentery,  42 

in    sprue,   360 

Morphine  injector's  septicaemia,  415,  416. 
See  also  ]Vhit]iiore's  disease 


INDEX 


691 


}vlosquito      destruction      as     prophylactic 
measure  against  yellow  fever,  372 

habits  of,  microfilaria  in,  275 

Mosquitoes,  destruction  of,  596 
dissection  of,  638 

time  of  day  at  which  biting,   71 

venom  of,  453 

Muco-enteritis,  from  drinking  water  con- 
taining non-pathogenic  bacteria,   553 

Mucorinal,  diagnosis  of,  630 

Mucous     membrane,     pathological      skin 

conditions  affecting,  476 
Mucus  in  faeces,  examination  of,  632 
Muraena   (fish  poisonous  by  bite),  447 
Musca  domestica,  224.  See:  also  House--fly 
Muscles,      calcification      of      Trichinella 

spiralis  in,  308 
Mussurana,    enemy  of  venomous   snakes, 

447 
Mycetoma  (Madura  foot),   478 
aetiology    and    pathology, 


470 


478 


fungi   producing,   478 
geographical  distribution, 


symptomatology,   480 

treatment,  482 

varieties,   481 

Mycosis  fungoides,   502 
Mydriatics    and   cycloplegics   in    c\e    dis- 
eases,  52 
Myelocene,  inunctions  in  keratosis  pilaris, 

473 

Myelocytes      in      spleno-medullary      leu- 
kaemia, 606 

Myiasis,  482,  483 

kinds  of  flies  causing,  482,  483 

Alyocarditis      considerable      in      typhoid 
fever  in  the  tropics,  218 

European,     fatal     complication     of 


European  relapsing  fever,  11 
Myocardium,  section  from  cases  of  beri- 
beri, 33Q,  340,  341- 
Myomata,  502 
Myotics  in  eye  diseases,  528 


Xaja,  species  of,  in  Africa,  431,  432 

bungarus     (king     cobra),     mortality 

caused   by,   429 

fasciatus,  characteristics  of,  428,  429 

tripudians  (cobra-di-capello),  photo- 


graph of,  425        _ 
Xaphthalin    suppositories    in    oxyuriasis, 

313 
Nasha  fever,  symptomatology,  396 

treatment,   396 

"  Nastin  "  for  leprosy,  188 
Xecator  americanus,  314-5 
points    of     difference    between 

the  Ankylostome  duodenale  and,  320 
Xeck,   fibroma  of,  496 

pendulous  fibroma  of  back  of,  497 

sarcoma  of,   500 

Negroes,    immunity    of,    from    sunstroke 

causes,  391 
Nemathelmia   (group  of  helminths),  231 
Nematodes,  morphology,  270 

pathogenic  to  man,  270 

preservation    and    examination    of, 

270,  321-2 


X'^eosalvarsan   in    f ramboesia    tropica ;    in- 
jection, intramuscular,  27 
intravenous,  26 

in  granuloma  inguinale,  469 

in    treatment    of    African    trypano- 
somiasis,   148 

Neosporidia,    5,    6 

Nerve  symptoms  in  typhus,  drugs  in,  380 

Nervous    symptoms    in    South    American 


trypanosomiasis,    157 
—  system,   disturbances 


of,   in  tropics, 


405 


Neurasthenia,  tropical,  405 
Neuritis,   peripheral,   endemic,   406 
Xeurofibrosis  of  Recklinghausen,    502 
Neurotoxins,    in    snake    venom,    import- 
ance  of,    440 
Night  blindness,    509 
Nitrates  in  water,  detection  of,  tests,  656, 

657 
estimation    of,    methods,     656,. 


657,  658 
—  in   milk. 


test   for,    569 


beri- 


Nitrogen,  deficient,   in   aetiology  of 
beri,  338-g 

estimation  of,  in  faeces,  process,  633 

— -_ —  ingestion   of,   565 

Nitrogenous  foods,  necessity  for,  562,  563- 
Nocardiasis,  ocular,   due  to  fungi,  511 
Nodes,  juxta-articular,  473 
Nomenclature,  international  rules  of,  230 

language,    rule  of,   230 

rule  of,  appropriateness,  231 

priority,    231 

Nourishment,  average,  for  man,  565 
Nucleus  of  protozoa,  3 

Nutrnegs  poisonous  in   large   doses,  454 
Nutrient  media,  vessels  used  for,  621 
Nutrition,    562 

O2,   absorption  in  sewage,  rate  of,   after 

filtration,   662 
Oatmeal  jelly  in  infant  feeding,  581 
(Edema  in  cerebral  stage  of  African  try- 
panosomiasis,   146 

localized,  in  African  trypanoso- 
miasis,  142 

Ointments,  application  in  different  forms 
of  tinea   (ringworm),  490-494 

nourishing   application    in   alopecia, 

470 

Oleate  of  iodine,  hot  fomentations  on, 
for  tropical   fever,    55 

Oleum  chenopodii  treatment  of  ankylo- 
stomiasis,  319-20 

Onchocera  (filaria)  volvulus,  life  history, 
300 

morphology,   300 

^ pathogenicity,  300 

Onyalai,  aetiology,  417 

definition,   416 

geographical  distribution,  417 

symptomatology,   417 

treatment,   417 

Ophidia,   423 

Ophthalmic  irritation,  510 

•  resulting     from     exposure     to 

wind    and   dust,    510 
Opisthoglypha,    423 
Opium  contra-indicated  in  yellow  fever, 

37^ 


69^ 


INDEX 


Opium,  tincture  of,  in  ama^bic  dysentery, 

43 

Opsonic  index,    164,   600 

definition   of,    164 

Opsonin,   600 

■Orchitis  and  hydrocele,  filarial,  s\mpto- 
matology,   281 

Oriental  sore,  504 

Ornithodorus  moubata  (tick)  found 
throughout   tro|)ical  Africa,    ig 

Orpimcnt  in  treatment  of  African  tr\-- 
panosomiasis,    148 

Ova,  detection  in   fceces,  637 

Ovary,   carcinoma  of,   502 

Oxalate  poisoning  in  aetiology  of  beri- 
beri,  337 

Oxidation,  water  rendered  potable  by,  561 

Oxidizable  organic  matter  in  water, 
method  of   estimating,  658 

Oxyhsemoglobin,  demonstration  by  spec- 
troscope, 612 

Oxyuriasis,   312 

parasite  causing,  312 

symptomatology,  313 

treatment,   313 

vermicularis,  morphology  and  life- 
history,  312 

ova  of,  637 

parasite   causing,  31: 


Oysters,    cholera    and    tyi^hoid    fever    re- 
sulting from  eating,   572 
Ozone,  sterilization  of  water  by,   556 

Facet's  disease  of  nipple,  495 

Paints,  application  to  mouth  in  sprue,  360 

Pancreas,     pernicious     manifestation     of 

malaria  in,  74 
Pancreatin  in  sprue,  360 
Pancreatitis,   chronic,  diagnosis  of  sprue 

from,  358 
Pandemic  diseases,    543 
Papalismus,  454 
Papular  fever,   symptomatology,   403 

treatment,  379 

Paragonimiasis      (endemic     haemoptysis), 

definition,   240 

diagnosis,   242 

distribution,  240 

morphology,  241 

parasite  of,    240 

pathology,   241 

symptomatology,   242 

treatment,  209,  242 

Paralysis,  general,  late  manifestation  of 

yaws,  25 
Parasites,    animal    and    vegetable,    stain- 
ing for,   604 

eye  diseases,  local,  due  to,  511 

in  aetiology  of  pellagra,   331 

infection  of   insects  with,   how 

effected,   7 

demonstration    in    laboratory    work, 


626 

—  in    haemoglobinuric    fever,    ciuestion 
of,  382 

—  macroscopic    examination    of    faeces 
for,  634 

—  malarial,  benign  tertian,  609 
in  blood,   staining  of,  607,  608 

in   brain,   mounting  and   stain- 


Parasites,   malarial,   in   brain,   manner  of 
showing  in   laboratory  work,  627 

living,    demonstration   of,   607 

Ciuartan,  609 

subtertian,  aestivo-autumnal  or 

malignant,  609 

varieties  of,  609 


vegetable 


m  £Etiology 


of  pellagra, 
causes  in   aetiology  of   beriberi, 


ing  section,  627 


331 
Parasitic 
340 

theory  in  aetiology  of  pellagra,  331 

Paris     Convention     (1903),     International 

regulations    to    prevent  importation    of 

cholera,     plague     and     yellow     fever, 

596-98 
Parotid   timiour,   mixed,    501 
Parrots,  epizootic  fatal  among,    189.     See 

also  Psittacosis 
Parthogenesis  in  protozoa,  4 
Pasteur-Chamberland  filter,  558 
use  in  phlebotomus  fever, 

361 
Peat,    avoidance  of,    in    catchment   areas 

for  water  supplies,   547 

in  water,  effect  on  leaden  pipes,  552 

Pediculosis,   483 

pathology,   483 

treatment,   484 

Pellagra,  jetiology,  329 

deficiency   disease,    572 

definition,   329 

diagnosis,  335 

eruption  of,  predisposing  factor,  540 

geographical  distribution,  329 

•  pathology,   333 

prognosis,    335-6 

■  seasonal  prevalence,  540 

symptomatology,  333-5 

treatment,  336 

• dietetic,  336 

Pemphigus   contagiosus,   484 

treatment,  484 

Penicilliaceae,  diagnosis  of,  630 

Penicilliosis,  485 

Peptone  waters,  glucose  and  lactose,  pre- 
paration of,  622 

Perforation  in  typhoid  fever  in  the 
tropics,   signs   of,   219 

Peritonitis,  fatal  in  ascariasis,  311 

in  severe  trichiniasis,  308 

Perleche,  478 

Permanganate  pills  in  cholera,  209,  210 

Perspiration,  importance  of,  in  tropical 
climates,    537 

Phagedaena   (tropical  sloughing),  485 

treatment,  485 

Phagocytes,    164 

Phagocytic  theory  of  protection  formed 
by  vaccines  and  sera,  600 

Phagocytosis,   164 

Phenacetin  in  yellow  fever,  371 

Phlebectasis,  filarial,  282 

Phlebotomus  fever,  setiology,  361 

carrier  of,  361,  362 

definition,  360 

diagnosis,  361 

— dift'erential,   361 

geogra))hical  and  seasonal  dis- 
tribution, 360,  361 

symptoms,  361 


INDEX 


693 


Phlebotomus  fever,  treatment,  361 

papatasii,     carrier    of    phlebotomus 


fever,  362 

characters, 

habits.  362 


life-historv       and 


Phosphorus,  in  food,  deficient,  in  aetiology 
■  of  beriberi,  ssg 

Photodynamic  theory  in  aetiology  of  pel- 
lagra,  330-1 
Pickles  for  preservation  of  meat,  575 
Piedra,  471 

treatment,   485 

Pigmentary  fever,   395 
Pigmentation  of  viscera 

explained,  72 
Pinguecula    resulting    from 

wind   and   dust,    510 
Pinta   (carate),  485 

symptoms,    485 

treatment,  486 

Pits  as  latrines  for  natives,    585 

deep,  as  latrines  for  Europeans,  5? 

for  natives,  586 


in  malaria,   how 


exposure    to 


Pityriasis   rubra ;   see   Dermatitis   exfolia- 
tiva 

versicolor ;    see    Tinea   versicolor 

Plague,   165 

abortion    in,    173 

ambulatory,    174 

antitoxic  serum  in,  value,  599 

bacillus  causing,    168 

blood  changes  in,   173 

bubo,  inguinal,  external  appearance, 


173 


of. 


bubonic,    167,   174 
-  transmission 


to     man,     mode 


'/ j 


where 


.    171 

carrier   of,    171 

cause  of   death  in, 

—  historical    memoranda,    166 

—  in    rats,   acute,    i6g,    170 

— chronic,    i6g,    170 

—  incubation    period,    172 

—  introduction    into     countries 
obliterated,    543 

—  mode  of  onset,   173 

—  mortality,    174 

—  or  cholera  on  infected  ships,  quaran- 
tine  measures   respecting,    597 

—  pathology,    171,    172 

—  pneumonic,    167 

in  Manchuria,  how  started,  171 

primary   infection   in,    172 

primary   and    secondary,    174 

transmission,   mode   of,    171 

post-mortem  appearances,   172 


prodromal  symptoms,   172 
prophylaxis  against,  private, 
public,    175 


176 


—  septicsemic,  general  features,  174 
— ;  species    of   rat    principallv    infected 
with,    170 

resistant  to,   171 


—  spread  of,  by  ground  squirrel,    171 
by  rats,   167 

conditions   favouring,   539 

—  symptomatology,   172,   173 

— transmission   from  one  species  of  rat 
to  another,   170 

—  vaccine,    effect    on    case    mortality, 


601 


Plague,  varieties  of,  general  characteris- 
tics, 174 

Plasmodium  malariae,  cause  of  quartan 
malarial   fever,   j^ 

vivax,     cause     of     tertian     malarial 

fever,    73 

Platyhelmia   (group  of  helminths),  231 
Pneumonia    a    complication    of    African 

trypanosomiasis,    146 
lobular    and     lobar,     in     pneumonic 

plague,    172 
Podophyllin    in   treatment  of   tapeworms, 

269 
Poikiloxytosis,  606 
Poison   ordeals,   456 
Poisons  for  animals,   457 

for  fish,   457 

taken  accidentally  by  man,   453 

Polychromatic  cells,  (3o6 
Polymori^honuclears,    percentage    in    nor- 
mal  blood   count,  6ot 

when   increased   physiologically  and 

when    pathologically,    605 

Polyneuritis,  sciatic  nerve  of  fowl  suffer- 
ing   from,  342 
Ponos,    limited   to   young   children,   413 

resemblance  to  biliary  cirrhosis,  413 

symptomatology,   414 

Popliteal  nerve  in  case  of  acute  beri- 
beri,  342 

Pork,  inspection  in  proph\laxis  against 
trichiniasis,   309 

Porocephalosis,  geographical  distribution, 
325 

pathology,   325 

symptomatology,   325 

Porter-Clarke      process      for      softening 

water,   555 
I^otash,  permanganate  of,  sterilization  of 

water  by,    557 
Potassium  iodides  in  blastomycosis,   462 
in   framboesia  tropica,  27 

salts,  vegetable  products  rich  in,  563 

"  Poudrette  "  method  in  disposal  of  ex- 
creta,  590 

Precipitins,   action  of,  600 

Prepuce  and  legs,   elephantiasis  of,   288 

Preservatives,  chemical,   576 

external,    for  preservation   of  meat, 

57S 
Prickly  heat,  486 

aetiology,  theories  as  to,  486 

treatment,  486,  487 

Protargol  in  amoebic  dysentery,  43 

ointment    for    ulcerative    lesions    in 

framboesia  tropica,  27 

Protein  deficiency  theorv  in  cTetiology  of 
pellagra,  331 

foods,    proprietarv,    constituents   of, 

567 

Proteolytic  ferments,  441 

probability  of,  in  snake  venom, 

44,  441 
Proteroglypha,  423 
Protozoa     as     factors     in     causation     of 

tropical   diseases,  2 

classification,  4 

definition,  2 

diseases  due  to,    i 

life-history,    3 

morphology,   3 


694 


INDEX 


Protozoa,    of    pathogenic    significance    in 
man,   5 

origin   of   infection  by,   2 

reproduction   asexual,   3 

methods  of,  3 

transmission  of,   2 


Protozoal    diseases,    modes    of    transmis- 
sion, 7,  8 
Protozoology,  introduction   to,   2 
Pseudo-Banti's     disease,     417.     See     also 

Splenoinegaly,  afebrile 
Pseudo-kala-azar,  definition,  69 
geographical  distribution,  6q 

prognosis,  69 

symptoms,  69 

Pseudo-myxoedematous        symptoms        in 

chronic   stage  of   South  American   try- 
panosomiasis,  156 

Pseudopelade,  471 

Pseudoxanthoma  or  elastorrhexis,  502 

Psittacosis,  aetiology  of,    189 

definition,    189 

pathology,    190 

sypmtomatology,    190 

treatment,   190 

Psoriasis,  487 

-  treatment,  487 


Pterygium,    510 

resulting  from  exposure  to  wind  and 

dust,   510 

Pulex  irritans,  transmission  of  plague  by, 

Pulse  in  typhoid  fever  m  the  tropics, 
Pus,  spontaneous  evacuation   of,  in   liver 

abscess,  positions  of,  dangers,   52 
Pylorus,   carcinoma  of,   502 
Pyosis  Corletti   (1915),  484 
treatment,  485 

palmaris,  487 

Pyrethrum   powder   as  protection   against 

Ornithodorus  moubata,  21 
Pyrexia,    charts    of,    in    undulant    fever, 

192-3 

Quarantine,  596 

Quartz  lamp  in  sterilization  of  water,  558 

Quassia,    rectal    injections   in    oxyuriasis, 

Quinine  bihydrochloride  m  chronic  stages 
of  amoebic  dysentery,  43 

in   chyluria   and    lymphuria,    284 

intestinal    irrigation    Avith,  in    ciliar 

dysentery   (Balantidium  coli),  46 

poisoning,  theory  that  haemoglobin- 


uric  fever  is  result  of,  381 

Radiotherapy    in    granuloma    inguinale, 

469 
Radium,   in    varicose,    Ivmphatic   glands, 

282 
Rainfall,   533 

annual,  estimation  of,   546 

as  predisposing  cause  of  malaria,  71 

Rain-water,  storage  of,  54O 

collection  of,  545 

rejection  of  roof-washings,  546 

Rash  in  typhoid  fever  in  the  tropics,  217 
Rat-bite  fever,  aetiology,  398 
definition,  398 

geographical   distribution,  398 


Rat-bite  fever,  mortalit\-  in,  398 

symptomatology,  398 

treatment,   398 

Rats,      destruction      in      prophylaxis     of 

trichiniasis,  309 

extermination  of,    596 

• plague   in,    169,    170 

species     principally     infected     with 

plague,    170 

resistant  to   i^lague,    171 


—  spread  of  plague  by,    167 

—  transmission    of    plague    from    one 
species  to  another,    170 

Trichinella  spiralis  parasitic  in,  308 


Recklinghausen,   neurofibrosis   of,   502 
Rectitis,    gangrenous  epidemic,    cause   of 
death  in,  409 

■ definition,  408 

prevalence     among     chil- 
dren of  natives  and  animals,  408 

symptomatology,  408 

. — treatment      for      animals 


m,  14 


and   children,   409 
Refrigeration    for   preservation   of    meat, 

Refuse,  collection,  removal  and  disposal 
of,    in   tropics,    584 

dry,   disposal   of,   in  tropics,    592 

Relapsing  fever,  American,  13 
Asiatic,  13 

-, cause  of  sudden  death  in^ 

IS 
mortality,   15 

• parasite  causing,   13 

percentage      of      relapses 

symptoms,    14 

treatment,   15 

cause  of,  9 

diagnosis,    12 

diiTerential,    12 

of  yellow  fever  from,  37O" 

European,  cause  of.   10 

—  ■ ■  causes  of  death  in,  12 

—  ■ ■  complications,   11 

incubation,   10 

infection,         transmission- 

from   mother  to   foetus,    ic 

morbid  anatomy,  13 

parasite  of,    10 

prognosis,   12 

prophylaxis,   13 

relapse  in,   11 

symptomatology,   10,   11 

treatment,    12 

of   symptoms,    12 


geographical  distribution,  9 

■ — —  history   of,   9 

parasite  of,  carrier,  10 

transmission,  mode  of,  8,  9 

Reptiles,  classification,   423 

cranial  skeletons  of,  422 

general   features,  419 

geographical  distribution  and   iiecu- 

liarities,  427,   428 

heads  of,   420,  421 

poisonous,  manner  of  striking  prey. 


436 


venom  apparatus  of,  435 
vield     of     venom     of     various 


species,  436,   437,   438 


INDEX 


C^95 


Reservoirs,  construction  of,   552 
points    to    be    watched    before, 

55-  .  ,     , 

— —  filtration  of  water  in,  mctliod,  559 

pipe-supply  of  water  froni,   552 

Resorcin  and  salicylic  acid,   spirit   lotion 

of,    for    removal    of    horny    masses    in 

elephantiasis  of   legs,   286 
application     in    different     forms    of 

tinea  (ringworm),  491,  492,  493,  494 
ointment,    ap]ilication    in    xanthoma 


areatum,    506 
Respiration,    effects   of    tropical    climates 

on,  537 
Rhinitis   spastica    vasomotoria.      See  Hay 

ft'7>er,   tropical 
Rhino-pharyngitis     mutilans.      See     G{i?i- 

Rhinosporidiosis,     geographical     distribu- 
tion, 7 

treatment,    7 

Rhinosporidium   seebcri,  habitat,   7 
Rhizoplast    in    protozoa,    3 

Rice,   nutritive  value  of,   564,   565 
Rickets,  dietetic  causes  of,  571 
Ringworm,    diagnosis   of,   630 

fungi,   families  of,  489 

(tinea),  appearance  of  lesion,  489 

varieties  of,  490-494 

lesions     and     regions     of 

body  attacked,  490-494 
treatment,  494 

See  also   Tinea 


River  water  in  Khartoum,  bacteriological 
examination,  642 

River   waters,  classification    for   drinking 
purposes,  649,  650 

tropical,  purity  of,  547 

Rivers,     shallow,     avoidance     for     water 
supply,    547 

Rocky  Mountains,  spotted  fever  of,  374 

Rodent  ulcer,  495 

Rogers'    method    in     treatment    of    para- 
gonimiasis, 209 

09, 


in    treatment    of    cholera,    2 


210 
Russell's  viper,   431 
fatality  of  bite  of,  442 


Saccharin,  test  for,  59 
Saccharomyces  cerevisiae,  631 

pastorianus   (wild  yeast),  631 

Salamanders,  venomous,   toxicity  of,   448 
Salicylic    acid,    application    in    ichthyosis 

hystrix,   473 

as  preservative,  test  for,  578 

Saline  purgatives   in    Nasha   fever,   396 

solution,     intravenous     injection     in 

cholera,  210 

• isotonic,  613 

and  hypertonic,  compared 


results,  211 
Salines  in   ciliar  dysentery   (Balantidium 
.  coli),  46 

in   snake   bite,   441; 

normal,   in  blackwater   fever,   388 

Salisbury  cure,  in   sjMaie,   359 
Salol  in  chyluria  and  hmphuria,  284 
Salt   solution,    rectal    injections   in    oxyu- 
riasis, 3n 

44 


Salt  water,  distillation  of,  to  obtain 
drinking  water,   544 

Salts,  uses  of,  in  body,   563 

Salvarsan  in  chappa,  413 

in  framboesia  tropica,  26 

in  treatment  of  African  trypano- 
somiasis,   148 

Sambon,  theor\-  of,  relating  to  .S".  t/ian- 
so)ii,  254 

Sand  filters,   mechanical,    z,()u 

Sanitation  in   tropics,    584 

Santonin    in    ascariasis,    311 

in  oxyuriasis,  313 

in  sprue,  359,  360 

Saponin,   dangers   of,   in   mineral   waters, 

584 
Sarcina?,  arrangement,   162 
Sarcocystis  lindemanni,  6 

muris,  6 

tenellas  buboli,   habitat,   6 

Sarcodina    (Rhizopoda),   4,    5 

Sarcoma   (myeloid  ?)  of   lower  jaw,  497 

of  neck,  500 

see  also  Bone  sarcoma 

Sarcomatosis,  multiple,  502 
Sarcosporidiosis,  7 
Sardines,  dangers  of,    572 
Sausages,  nutrition  in,   567 
Scabies,   487 

treatment,  487 

Seal]),   elephantiasis  of,    293 
Scarlet  fever,  no  spread  of,  in  tropics,  401 
Schistosoma     haematobium,     infection     in 
schistosomiasis,      incubation     time     of, 
248,   249 

symptomatolog\',  248 
treatment,  248 


life-history,  244 
—  mori3holog\-       of 


male       and 


female,  243 
ova  of,  243,  637 

—  ■ percentage    of     population     of 

Egypt  infected  with,  242 

—  japonicum  from   dog,   251 

infection  in  schistosomiasis,  251 

diagnosis,  254 

geographical   distribution,   251 

ova  of,  637 


pathology,   252 

prognosis   bad,   254 

schistosomiasis   spread   by,   2^1 

symptomatology,    254 

treatment,   254 

—  mansoni,      infection      in      schistoso- 
miasis, theory  of  Loos,  255 
theorv    of     Sambon. 


254 


ova  of,  637 


Schistosomiasis,  causative  parasites,  242 
geographical  distribution,  242 

infected   with   Schistosoma   haemato- 
bium, low  mortalit\-  in,  249 

Schistosoma  japonicum,  251 

post-mortem   appearances, 

^52,  253  _ 

intestinal,      geographical      distribu- 
tion, 255 

pathology,  25!') 

prognosis,  256 

— ^  treatment,  256 


c^oo 


INDEX 


Schistosomiasis,   pathology,  245 

post-mortem  appearances  of  bladder 

in,  245,  246 

prevention,  conclusions  as  to,  based 

on  Loos'  hypothesis  and  on  Bilharzia 
Mission   (1915),  contrasted,  249,  250 

symptomatology,  256 

treatment,  256 

conclusions    as    to,    based    on 

Loos'  hypothesis  and  Bilharzia  Mission 
(1915),  contrasted,  249,  250 

Schiiffner's  dots  in  benign  tertian  para- 
site, 609 

Sciatic  nerve  of  fowl  suflfering  from  poly- 
neuritis, 342 

Scorpions,  venomous,  mortality  in  chil- 
dren from,  449 

stings  from,  mortality,  449 

symptoms,  449 


treatment, 


450 
290 


of 


Scrotum,  elephantiasis  of,  289, 
Scurvy,  dietetic  causes  of,  571 
Seaports,      large,      recommendations 

Paris   Convention  regarding,   597 
Sea  serpents,  42^.     See  also  Hydrophina 
Sebaceous   glands,    high    development    in 

natives  of  Tropics,  458 
Seborrhoea,  488 

treatment,  488 

Sections,  mounting  of,  on  slides,  626 

preparation  of,  624 

staining  of,  613,  626 

Septicaemia,  development  in  plague,  172 

morphine  injections,  4,  15,  416.    Sec 

also   Whitviore^s  disease 

Sera,  antitoxic,  599 

comparative     value,     in     treat- 
ment of  various  diseases,  599 
preparation  from  horse,  599 

protection    afforded    by,    hypotheses 

accounting  for,  600 

Serotherapy     in     typhoid     fever     in     the 

Tropics,  222 
Serum  in  prevention  of  snake-bite,  444 

Lustig's    and    Galeotti's,    in    prophy- 
laxis of  plague,  176 

Yersin's,   in   prophylaxis  of   plague. 


176 
Sewage,  disposal  of,   care  of  Chinese  in, 

587 

■  effluents,  examination  of,  662 

examination   of,   662 


Sexual  desire  in  cerebral  stage  of  African 

trypanosomiasis,  141; 
"  Shake  ''  cultures,  624 
Shiga-Kruse    type   of    dysenter\-   bacil 

619 
Ships,    health)^,    quarantine    measures 

specting,   597 
infected,     quarantine     measures 

specting,   597 
with  yellow  fever,  distance 


lus. 


re- 


re- 


anchorage  from  shore,  372 
—  suspected,    quarantine   measures 


of 


re- 


specting, 597 
Side-chain    theory, 

tection   afforded 

601 
Simaruba  officinalis  in  nmnpbic  dvsentery, 

prescriptions,  44 


Ehrlich's,    of    protec- 
by  sera   and  vaccines. 


Simpson,    W.    J.,    results    of    inoculation 
of   living  vaccines  against  cholera,  212 

summary    of    cholera    epidemics    in 

Europe,  203-4 

Simulidse  in  setiologx    uf  pellagra,  2>2>~ 

Siriasis,  539 

Sistrurus  catenatus    (Prairie   rattlesnake), 

430 
Sitotoxismus,  453 
Skin,   condition  of,   in   cerebral    stage   of 

African  trypanosomiasis,   145 

diseases  of,  458 

elimination  of  toxins  by,   in   yellow 

fever,  371 

fibromatous     condition     of,     curious 


example,  496 

in  typhoid  fever  in  the  Tro]:)ics,  217 

pigments,  488 

Sleeping    sickness    stage    in    African    try- 
panosomiasis,   144-6 
Slides,  method  of  cleaning,  604 
Smears,   manner  of  staining,  613 
Smegma  bacillus,  616 
Smoking,   avoidance  in   sprue,  359 
Snake-bite,  antitoxic  scrum  in,  value  of, 

599 

deaths  per  annum  due  to,  in   India, 

419. 

immunity       from,       acquired       and 

natural,  444 

maintenance  of  strength   of  patient 

in,  445         . 

prevention    of    secondary    infection 

in,   445 

prophylactic  measures  against,  446 

symptomatic   treatment   in,   445 

symptoms,  441 

treatment,  443 


Snake    venom,    aid    in    cxecretion    of,    in 

treatment  of  snake-bite,  445 
apparatus  of  poisonous  reptiles. 


435 


—  characters  of,  438 

—  manner  of  analysing,  440 
varieties  of,  438 


Snakes,  cranial  skeletons  of,  422 

heads  of,  420,  421 

Soamin  in  treatment  of  African  trypano- 
somiasis,  148 
vSodium  antimonyl,  in  kala-azar,  61 

bicarbonate  in  onyalai,  417 

bisulphate,    tabloids    of,    in    schisto- 
somiasis, 250 

hyposulphite,      for     purification      of 

water,  556 
Soil,   533 

disturbance    of,    iMedisposing    cause 

of  malaria,  71 

permanent    damjiness    of,    injurious 


to  health,  533 
Solids   in   suspension   in   sewage,   method 
of  estimating,  662 

total,  in   water,   method  of  estimat- 
ing, 653  . 

Solutions,  cleansing  and  antiseptic,   526 
Soya  bean   (glycine  soja),  nutritive  value 

of,  564 
Sparganum  (human  tapeworm),  261 

producing  acne-like  eruption,  261 

Sjiectroscopic  examination  of  blood,  612 


INDEX 


by) 


Spiders,  vt-numuus,  449 

effect  of  venuin,  4-,i 


stings  from,  mortalit\-,  450 

symptoms,   450 

treatment,  450 


Spirillum  cholerae  asiaticae,  diagnosis  of, 
621 

I"" inkier-Prior,     diff'erentiation 

Koch's  comma   bacillus,   621 

(vibrio-proteus),   621 

Spirit     lotion,     application     to     skin 

inickly  heat,   formula   for,  487 
Spirochaeta    carteri    cause    of    Asiatic 

lapsing  fever,   13 

duttoni,    10 

recurrentis,    10 


from 


m 


re- 


Spii^ochsetes  causing   relapsing   fever,   9 

field  rat  reservoir  host  for,   17 

S|Mrocha;tosis  icterohsemorrhagica  (Weil's 

disease),  ajtiology,   17 

definition,    17 

diagnosis,  18 

geographical  distribution,    17 

history,    17 

prognosis,   18 

symptomatology,   17 

treatment,    19 

Spleen,   enlargement    in    relapsing    fever, 

13       .  . 

microscopical  appearance  in  African 

trypanosomiasis,    139 

Splenomegaly,   afebrile,    definition,   417 

geographical   distribution,  417 

symptomatology,  417 

treatment,  417 

Sponge-fishers'  asthenopsia,   509 
Sporadic  diseases,  542 
Spore  formation  in  protozoa,  4 
Spores,  method  of  staining,  61^ 
Si)orogenes    test    for    bacteriological    ex- 
amination of  water,  643 
Sporotrichosis,  488 

ocular,  due  to  fungi,  511 

treatment,  488 


Sporozoa,  4 

S]50tted      fever 

aetiology,  374 


complications,  375 
definition,  374 
diagnosis,  375,  376 

differential,  375, 

geographical     distribution 


376 


and  seasonal  incidence,  374 
in     Montana, 


37'- 


37(> 


mortalit\', 

prophylaxis    against, 

incubation   period,  375 
pathology,  374 
prognosis,  376 
symptomatolog\-,    375 
treatment,  376 
(conjunctivitis   aestivalis), 


Spring  catarrh 

516 

Spring  water,    548 
Springs,  contamination  of,  549 
Sprue  (psilosis),  aetiology,  352-6 
causes  of  death  in,  357 

condition  of  tongue   in,  357 

definition,  352 

•  diagnosis,    35S 


Sinuc,    diagnosis,    differential,    358 

geographical  distribution,  352 

pathology,  3^,6 

post-mortem  examination,  356 

-- — •  state  of  blood  in,  3^7 

treatment  by   Cantlie's   method,    350 

by  drugs,  360 

' by  vaccines,  360 

dietetic,  358,  359 

local,   360 

symptomatology,  357 

yeast  infection  in,  357 

••  Stab  ''  cultures,  624 
Stains,   choice  of,  604 
Staphylococci,   arrangement,    162 
Staphylococcus     i^yogenes     aureus,     dia- 
gnosis of,  620 

Starvation,  death  from,   564 
Steam  as  means  of  disinfection,  593 
^ —  pipes  in  sterilization  of  water,  558 
Stegomyia    calopus    carrier    of    virus    of 
yellow  fever,  365,  366,  367 

(fasciata),  adult  female,  373 

eggs  and  larvae,  373 

habits,   373 

notes  on,  373 

transmission     of     dengue 


for   preservation   of 
in     vellow    fever. 


of      Rocky      Mountains,  271 


hy,  37(} 
Sterilized   enclosures 

meat,  575 
Sternberg's    treatment 

formula  for,  371 
Stomatitis,  diagnosis  of  sprue  from,  358 
Stools    in   typhoid    fever   in    the   Tropics, 

217 
Storage  tanks  for  rain  water,   ^4'^' 
"  Streak  "'  cultures,  624 
Streptobacilli,    162 
Streptococci,  arrangement,   162 
in  water,  method  of  enumeration  of, 

652 
Streptococcus  pyogenes,  diagnosis  of,  620 
Streptothfix  madura,  diagnosis  of,  630 
Strongyloides  stercoralis,  270 

-  intestinal  catarrh  produced  by, 


Sublimate,  corrosive,  as  disinfectant,  594 
Sullivan's    diamond    drill    for    producing 

bore  well,  551 
Sulphates  in  amoebic  dysentery,  44 
Sulphur   anhydride    and    sulphurous   acid 

gas  as  disinfectant  for  houses,  595 
ointment,     application    in    different 

forms    of    tinea    (ringworm),    490,    493, 


494 


in 


trichomycosis,   495 
in  scabies,  487 


in  seborrha>a,  488 

Sulphurous  acids  and  sulphites  as  pre- 
servative, test  for,  579 

Sun,  rays  of,  in  Tropics,  effect  of  on 
skin,   459 

Sunlight,  bacteria  susceptible  to,  and  re- 
sistant to  eft'ects  of,  645 

direct,  simple  method  of  disinfec- 
tion,   592 

pathological    effects,    539 

predisposing    factor    in    eruption    of 

pellagra,  540 

Sunstroke,  539 

see  also  Heai  stroke 


Ocjb 


INDEX 


Surtaci'  water,  547 

catchment  areas,  site  of,   547 

Sweat,   secretion   of,   in   excess   in   natives 

of  Tropics,  458 
Synovitis,  acute,  of  knee  associated  witli 

filaria  infection,  294 
Syphilis,  488 
diagnosis    bv    \Va>-eiinann    leaction, 

610,  611 
predisposing      factor     m      ha>moglo- 

binuric  fever,  384 
Svjjhilitic  ulcers,   504 


Tabks^  late  manifestations  of  \a\vs,   25 
Tablet  foods,  concentrated,   582 
Taenia     saginata     affecting     muscles     of 
tongue  and  of  mastication  of  cattle,  26O 

largest  human   tapeworm,  265 

solium,  264 

Tannic  acid  in  ama^bic  d\senter\ ,  43 
intestinal     irrigation    with,     in 


ciliar  dysentery   (Balantidium  coli),  46 
Tapeworms  found  in  man,  list  of,  260 

treatment,   preliminary,  269 

prescription    for,    269 

prophylactic,  270 

thorough,  269 

See  also  Cestoda  i)athog.entc  to  iiuiii 


Tapioca,  564 

elimination     of    poisonous    elements 

from,  454 
Tarabagan    (Arctomys    bola?),    spread    of 

lineumonic    plague    in    Manchuria    by, 


i/t 


Thresh's  disinfecloi,   59^ 

Thvmol  treatment  of  ank\lo.,tuniiasis, 
318-9 

Tick  fever,  African,  mode  of  trans- 
mission,  8 

Ticks,  largest  specimens  of  order  of 
Acariaa,    19 

manner  of  propagation,   19 

venom   of,    infection   by,    symptoms. 


Tartar    emetic    m 

469 

in  treatment  of  African  try- 
panosomiasis,  148 

method    of    administration     in 

treatment  of  African  trypanosomiasis, 
149 

Tattooing,  488 

risks  of,  488 

treatment,  489 

Tea,  cold,  w4iy  a  suitable  drink  for 
travellers,  555 

qualities  of,   582 

Telangiectasis,   multiple,   502 
Telosporidia,  4,  6 
Temperature  of  air  in  tropics,   531 
Tetanus,  antitoxic  serum  in,  value,  599 

bacillus,  diagnosis  of,  617 

Telracocci,  arrangement,   162 
Tetramitus  mesnili,    5 

— parasite  of  ciliar  d\  ,-,enter\-,  47 

Tetrodin  in  poisonous  fish,  448 
Tetrodonic  acid  in  poisonous  fish,  448 
Theft,  propensity  to,  in  cerebral  stage  of 

African  trypanosomiasis,    14^ 
'Thermal    methods    of    sterilizing    water, 

558 
'Thiosinamin   injection   in  elephantiasis  of 

legs,  286 
'Thiosulphite    for    purihralion    of    water, 

Thoracic  duct,  blocking   ot.    in    tilanasis, 

279 
Three-day  fever.    See  Phleboiovuis  fever 
Thresh,  j.  C,  method  of  inuifxing  water, 

550 


450,  451 


treatment,   451 


Tinea  alba,  490 
lesions    and    regions    attacked. 


n-anuloma    inguinale, 


490 

parasite,   490 

regions  attacked,   490 

treatment,  490 

-  albigena,  490 

parasite,  490 

treatment,  490 

-  barbae  (sycosis),  490 
lesions     and     regions    at- 
tacked, 490 

liarasite,  490 

treatment,  490 

capitis    (tonsurans),    lesions   and    re- 
gions attacked,  490 

-^ parasite,   491 

treatment,  491 

cincinata    (ringworm   of    the    bod.\), 

lesions  and   regions   attacked,   491 

parasite,   491 

treatment,    491 

cruris    (eczema  marginatum,   dhobie 

itch),  lesions  and  regions  attacked,  491 

parasite,  491 

treatment,  491 

decalvans,  492 

flava,   lesions  and   regions  attacked. 


492 


parasite,  492 
treatment,  492 


—  imbricata,     lesions    and     regions    of 
body  attacked,  492 

parasite,  492 

treatment,  493 


—  intersecta,    lesions    and    regions    of 
body  attacked,  493 

parasite,  493 

treatment,  493 

nigra,  493 


lesion     and     regions     of     l:)()dy 

attacked,  493 
parasite,  493 

nigro-cincinata,    lesion    and    regions 

of  body  attacked,  493 

l)arasite,   493 

treatment,  493 

nodosa,   471,   493 

treatment,  471 

ocular,  due  to  fungi,  511 

palpcbralis,   494 


(ringworm),  489 

Sabouraudi    tropicalis,    lesions    and 

region  attacked,   494 

parasite,   494 

treatment,   41)4 


tonsurans,  489,  490 
ungium,  lesions,  494 

parasite,  494 

treatment,  494 


INDEX 


6(j9 


Tinea    versicolor    (Pityriasis    versicolor), 

lesions  and  regions  attacked,  494 

— ■  parasite,   494 

treatment,  494 

Tissue  changes  in  sections,  staining  for, 

604 
Tissues,  embedding  of,  in  preparation  of 

tissues,  625 
•  fixing  of,  in  preparation  of  sections, 

624 

hardening  of,  in  pre])aration  of  sec- 
tions, 625 

Toads,  venomous,   slightlv  toxic  to  man, 
,448 

1  ongue   and   mastication,    muscles  of,    in 
cattle  affected  by  taenia  saginata,  266 

condition  of,  in  sprue,  357 

denuded   epithelium   of,   diseases    in 

which  seen,  358 

leukoplakia  of,  477 


Townships,  planning  and  construction  in 

tropical    districts,    536 
Toxicity   theory   in  aetiology   of   pellagra, 

Toxins,  elimination  in  \ellow  fever,  370, 

371  . 

Trachoma,  aetiology,  513 

complications  and   seciuelse,   573 

definition,   513 

(granular  conjunctivitis),  512 

surgical  remedies  for,  515 

symptomatology,  513  - 

treatment,  514 

Trematoda  pathogenic  to  man,  classifica- 
tion, 232,  236 

habitat,   235 

life-history,    235 

morphology,    234 

pathogenic,   varieties,   236 

—  treatment,  236 

Trematodes,  ova  of,  637 

preservation     and     examination     of, 

322 

Trench  fever,  aetiology,  400 

— ■ —  definition,  400 

distribution,    400 

symptomatologv',  400 

treatment,  401 


Trenches,  deep,  unsatisfactory  as  latrines 

for  natives,  586 

prepared  as  latrines  for  natives,   ^86 

shallow,  as  latrines  for  natives,   s8s 

Trenching  and  cultivation  in   disposal  of 

excreta,   590-592 
Treponema   pertenuis,    framboesia   tropica 

(yaws)  due  to,  21 
Trichinella       spiralis,       calcification       in 

muscles,  308 

cysts  of,  306 

larvae  of,  306,  307 

m.orphology,  306,  307 

■  iiarasite     causing     trichiniasis. 


306 

of  rats,  30S 

Trichiniasis,   definition,   306 

geographical  distribution,  306 

parasite  of,  306 

prophylaxis  against,  309 

symptomatology,  308 

treatment,  308 

Trichocephalus  dispar,  ova  of,  637 


Trichocei^halus      trichiuris      (whipworm), 

morphology,    305 
parasite     causing     tricho- 

cephaliasis,  305 

pathogenicity,   306 

Trichocephaliasis,  definition,  305 

parasite  of,  305 

treatment,  306 

Trichomonas  hominis,  5 

intestinalis,   characters,   5 

parasite  of  ciliar  dysentery,  47 

vaginalis,   5 

geographical   distribution,   5 

Trichomycetes,  divisions  of,  C29 
Trichomycosis,  494 

capillitii,  472 

treatment,  495 

Trichonocardiasis  (nodules  on  the  hairs), 

4gj 
Trichophyton    megalosporon    (ringworm), 

631 

Trichophytons,  489 

and     microsporons,     dift'erence     be- 
tween,  489 

Trichorrhexis   nodosa,   472 

treatment,   472 

Tropical  diseases,  protozoa  as  factors  in 
causation   of,   2 

liver,    Europeans   attacked   by,    55 

internal    medications   in,    55 

Trypanosoma  brucei  (rhodesiense),  127 
animal   susceptibility   to,    130-1 

carriers  of,    131 

—  division   of,    129 

general   features  of,   127 

geographical     distribution     of, 


130 

group   of,    127 

history  of,    130 

morphology   of,    130 

notes   on,    157 

reservoir  of,   131 

—  caprae,    129,    137 

—  cruzi,    agamony   of,    155 

cause  of  South  American  try- 
panosomiasis,   154 

microscopical    examination    of, 

156 


post-mortem,    156 


131 


schizogony  of,   154 

sporogony  of,    155 

equiperdum,  128,   158 
evansi,    128 
gambiense,    125,    128 

■  animal  susceptibility  to,    132 

carriers   of,    133 

conclusions  as   to,    134 

cycle  of  development,    132 

geographical     distribution     of, 

history  of,    131 

morphology   of,    132 

reservoir  of,    134 

pecorum,   128 

carriers  of,    135 

development  of,  128,  136 

general   features  of,    128 

group  of,    128 

morphology   of,    135 

pathogenicity  of,   135 

reservoir    of,    136 


700 


INDEX 


Ti\  panosoma  siiniae,   128,   136 

uniforme,    129,    136 

vivax,    120,    136 

development  of,    121; 

— —  general  features  of, 

group  of,    129 

Trypanosome    cazalboui,    notes 


I2g 


on. 


157, 


159 


dimorphun,    notes  on,    160 
equinum,   notes  on,    158 
evansi,  notes  on,   157 


hippicum,   notes  on,   159 

Soudanese,   notes  on,    159 

Trypanosomes,   classification   of,    126-7 

habitat  of,   126 

methods  of  searching  for,    147 

pathogenic,    Central   African,    127 

groups  of,  general  charac- 
ters,   127-137 

Trypanosomiasis,    African,    aetiology    of, 
124-5 


cases  of,  143 
complications,    146 
definition    of,    122 
diagnosis  of,    146-7 
geographical  distribution,  123-4 
history  of,    122 

macroscopic    appearances,    post- 
mortem, 137 

■ microscopic  appearances,  post- 
mortem,   138 

pathology  of,    137 

prognosis   of,    147 

prophylaxis  against,    150 

symptoms,    summar.\-  of,    140 

symptomatology  of,    139 

treatment  of,    147-8 

—  development,    conditions   favourable 
for,    540 

—  mammalian,  pathological,  notes  on, 
157 


—  parasite  of,    125 

—  South  American,  aetiology  of,   154 

chronic,    with    acute    and 

subacute  exacerbations,   157 

history  of,   154 

])athology  of,    155 

prophylaxis  against,    157 

—  — ■  symptomatology  of,  156 

treatment  of,   157 

transmission,  mode  of,  8 


low   water   m   tropics, 


Trypanosomid?e,    5 
Tube   well    for  sha 

.,551 

1  ubercle  bacillus,  diagnosis  of,  615 

in   milk,    test   for,    570 

Tubercular  ulcers,  504 
Tuberculosis,  antitoxic  serum  in,  599 

in     animals,     recommendations     of 

Royal     Commission     on     Human     and 
Animal   Tuberculosis,    574 

Tumour,  leaking,  discharging  fluid  giv- 
ing reaction  of  bile,  501 

Tumours,  495 

Turpentine,  application  in  tinea  flava. 
492 

— —  oil,  application  in  tinea  capitis,  491 

Typhoid  bacilli,  removal  from  water, 
chemical   process   for,    556 

bacillus,    destruction    bv    storage    of 

water,    554 


T\phoid  bacillus,  in  water,  dithculties  of 
detection,  652 

-  method    of    detection    of, 


652 


fever,   carriers,   fa;cal,  214 

fly,  214 

urinary,   214 


case  incidence  and  case  mor- 
tality, affect  of  anti-typhoid  vaccine 
on,  601 

-  diagnosis    b\     \A'idal    reaction. 


611 

spotted     fever    of    Rocky 

Mountains    from,    2,j^ 

epidemic  following  use  of  con- 


taminated   shallow   wells,    550 
sources  of,  215 
house-flies,   carriers  of,   224 
in   tropics,   213 

causes  of  death,  218 

complications,   218 

diagnosis,  219 

-  bacteriological. 


importance  of,  219 
liability     of     freshly 

arrived  Europeans  to,  215 

pathology,  215 
symptomatology,  217 
treatment,  222 
in  special  sym- 


ptoms, 223 

sources  of  infection,  214 


Typhus  fever,  aetiology,  213,  379 

and    spotted     fever    of    Rocky 

Mountains,  similarity  between,  376 
complications  in,  380 

definition,  379 

distribution,   379 

symptomatology,   379 

treatment,  380 


Ulcer,    perforating,    amputation    for,    in 

the  foot  of   lepers,    185 
Ulcerations,  tropical,  502 

causes  of,    502 

nomenclature  of,   503,   504,   505 

treatment,    505 

Ulcers,  blastomycotic,   503 

cancerous,    503 

diphtheroid,    ^03 

framboesial,  504 

infantile,    504 

interdigital,    ,04 

leprotic,  504 

or  elephantoid,    ^503,    ^04 

septic,    504 

■  syphilitic,    504 

tubercular,    504 

varicose,  503,  505 

Ultra-violet  ravs  in  sterilization  of  water, 

.55,8 
Undulant   fever,   aetiology  of,    190 

complications   of,    195 

definition  of,   190 

diagnostic  features,   195 

geographical     distribution     of. 


190 


modes  of   infection,    191 

pathology  of,    191 

post-mortem  appearances,   191 

prophylaxis  against,   195 


JNl-fEX 


701 


Undulant  fovcr,  symptomatology  of,   iqi, 
104-5 

■ transmission,  modes  of,   540 

treatment   of,    195 


United    States,     mortalit\'     from     yello\v 

fever  in,  370 
Urinary  carriers  of  typhoid   fever,  214 
Urine   in   blackwater   fever,    387 

in   chyluria   and   lymphuria,   283 

LTrobilin,     increase     of,     in      faeces,      in 

haimolytic  diseases,  634 
Urotropine    in    chvluria    and    Ivmphuria, 

284 
Uterus,  cervix,  carcinoma,  502 

\'accination,   definition,    5q8 
Vaccine,     Haffkin(>'s,    in    prophylaxis    of 
plague,    176 

dosage,  176 

inoculation  against  cholera,  212,213 

Vaccines,   autogenous,   598 
in    Archibald's    fever,   sgj 

in  dermatitis  cupoliformis,  465 

in  pyosis  Corletti,  485 

classification   of,    590 

compound,   602 

imported,    manner    of    preservation, 


598 


Verruga     peruviana,     ^vvvrc     iy])C     (Car- 
rion's  fever),   364 

— —  symptomatolog\-,    364 

treatment,   365 

Vertigo,   paralytic,   endemic,   40O 
Vesicular  fever,  diagnosis,  403 

Vibrio-proteus.      See   S-pirillum.  F/iik/cr- 

Prior 
Villages,   native,   planning  and  construe 

tion   in   tropical   districts,    536 
Vipera     russelii      (daboia,     or     Russell's 

viper),  431 
Viperidse,  426 
Viperinse,    426,   430 

in  Africa,  432 

Viperine    venom    (snake    bite),    post-mor- 
tem,  443 

—  symptoms,  442 

^'iruses,    filterable,    561,    562 
\'itamines,  569 
A'oit's   standard  diet,    565 
\^olvulosis,  300 

geographical   distribution,  300 

\'omit  of  yellow   fever,  368 
Vomiting  in  ackee  poisoning,  455 

in   blackwater    fever,    drugs    in    cure 

of,  388 

in    cholera,    treatment,    210 


living    and    devitalized,    inoculation       \'ulva,  elephantiasis  of,  292 


against    cholera,    213 

—  protection    afforded    by,    hypotheses 
accounting   for,   600 

—  sensitized,    599 

—  streptococcal   in    sprue,   360 
table  of,  with  doses,   599 


Vacuoli   in   protozoa,   3 

Vacuum   apparatus    (Elliott  and   Paton's) 

for   steam   disinfection,   595 
Van    Gieson's    stain    in    staining    sections, 

627 

• use  of,  604 

^^ariola    in    India   and   Africa,    401 
\'egetable  matter  in  water,   ill-eft"ccts  of, 

products,  rich  in  potassium  salts,  563 

Vegetables,  deficient,  in  aetiology  of  beri- 
beri, 339 

green,  transmission  of  cholera  by,  206 

Vegetarianism,    580 
A'cldt    sore,    503,    505 

Venom,  absorption  of,  in  snake  bite,  pre- 
vention of,   443 

manner  of  neutralizing,  444 

See  also  Snalie  venom 

Venoms,   diseases  due  to,   418,  419 
Vcrrucae,  495 

Verruga  peruviana,  retiology,  363 

atypical,    365 

blood   condition   in,  364 

definition,  363 

■ —  erythema  of,  364 

geographical   and  seasonal   dis- 
tribution,  363 

histopathology,  363 

history,   363 

mild  type,   364 

pathology,   363 

prognosis,   365 

-_ regional        distribution,       with 

various  resulting  lesions  and  symptoms, 
^61; 


Wars,  relation  of  cholera  epidemics  to, 
204,   205 

Warts,   495 

Washing  water,  cleansing  of,  method 
described,    560,    561 

Washington-Lyon  apparatus  for  disin- 
fection by   steam,    595 

Wasps.     See  Bees 

\Vassermann  reaction  (Fleming's  modi- 
fication), diagnosis  of  syphilis  by,  610, 
611 

-  substances     required 


for,   610,    611 


611 


technique     of,'    610, 


Water    and    faeces,    bacteriology    during 

monsoon   weather,  646 
amount  required   daily   for  personal 

and  domestic  use,   544 

analysis    of    sample    of,    certificate, 

662 

as  thirst  quencher,   582 

bacteria   in,  enumeration  by  British 

methods,   650,   651 

boring   for,   545 

carriers,  Hindu,  vessels  used  by,  552 

Mahommedan,       infection      of 

water  by,  5 151 

chemical   examination  of,  653 

closets    in    tropics,    588 

containing    peat,    effect    on    leaden 

water-pipes,  552 

contamination,    source    of,    methods 


of  tracing,  553 
control  of,  by  medical  officer,  553 

distilled,    aeration    of,    545 

examination,  639 

bacteriological,   640,  64 1 

-  in     India,     standard     for. 


645,   646 


tests   for,    642,    643-646 


702 


INDEX 


Water  examination,  biological,  640 
physical,   640 

filtration   of,    558 

hard,  not  injurious  to  health,   S'^2 

pathology  of,  S'52,  553 

I)urification,    554 

by    precipitation,    555 

by  storage,  554     ■ 

chemicals  used  for,   555 

■  rendering  potable  by  oxidation,    s*"'! 

soft,   ill-effects   of,   552 

softening  of ,  chemicals  used  for,  555 

solvent  uses  of,  in  diet,   563 

sources   of,    544 

sterilization   aided   by  storage,    554 

by  electrical   methods,   558 

by  thermal  methods,   558 

subterranean,   548 

classification  of,  548 

transmission   of  cholera  by,  205 

transport  of,   551 

unfiltered,  spread  of  schistosomiasis 

by,    250 

\Vatercre5s,  dangers  of,  572 

Water-pipes,  iron,  diminution  in  dia- 
meter, 552 

Water  supply  pipes,  dimensions  of, 
method  of  ascertaining,  546 

Weigert's  inethod  for  staining  micro- 
organisms, 614 

WeiTs  disease.  See  Spirochcetosis  ictero- 
hcemorrhag'ica 

Well  and  spring  waters,  classification 
for  drinking  purposes,  650 

protected,  plan  of,   550 

—  shallow,  bacteriology  of  water  from. 


647 

water  in   Khartoum,  bacteriological 

examination,  643 
Wells,  deep,  551 

shallow,   548 

contaminated,  use  of,  followed 

by  t.vphoid  fever  epidemics,  550 
contamination  of,    549 


Whey,   568 
Whipworm. 

tirus 
White    men, 

impossible. 


See    Trichocephahis    trichi- 
existence    in    tropics 


racial 
.    538 

Whitmore's  disease,  aetiology,  415 

common  in  drug-takers,  415 

■ definition,  415 

pathology  and  symptomato- 
logy, 415,  416 

Widal  reactions  in  diagnosis  of  typhoid 
fever,  219,  611 

method  of  performance,  611,  612 

Wind  and  dust,  exposure  to,  causing 
l)inguecula  i)terygium  and  ophthalmic 
irritation,   510 

Women,  men  and  children,  food  neces- 
sary for,  compared,   564 


XANTHOM.A  areatum,  506 
treatment,   506 

diabeticorum,    502 

lilanum,    502 

tuberosum,    502 


Xenopsylla    cheopis    (rat-flea),    transmis- 
sion  of   plague   by,    171 
Xerosis,    510 

among   debilitated   children,    510 

X-ray  treatment  of  tropical  ulcers,  505 


Yaws.     See    Framhoesia   tropica 
Yeast,  infection   in   sprue,   357 
Yeasts,   staining  of,  632 
Yellow  fever,  blood  condition  in,  367 

course,  crisis  and  termination. 


369,  370 


370 


definition,  365 
diagnosis,  370 

differential,   370 
in   early   stage,    imported, 

disinfectant    measures   against. 


?>1^ 


■  endemic  centres   of,   366 

endemicity  of,  mean  tempera- 
ture  necessary   for,   539 

geographical  distribution,  366 

immunity  to,  368 

natural,     in     very     young 

children,   368 

importation  of  cases  into  re- 
gions free  from  Stegomyia  callopus 
not   dangerous,    543 

incubation   period,  369 

mortality,    370 

pathology,  367 

post-mortem  findings  in  bodily 

regions   and   organs,   368 

prognosis,  370 

prophylaxis   against,   371,   372 

Boyce's        summary. 


372 

—  spread    of,    dependent   on    pre- 
sence of  mosquitoes,  539 

factors  necessary  for,  371 

symptomatology,  369 

—  transmission,   mode  of,   8 

treatment,   370 

bv     alleviation     of     svm- 


370,   371 


ptoms,  371 
b\-   elimination   of   toxins, 

-  dietetic,  371 

indications  for,  370 

virus  of,   366,  367 

carrier,  365,  366,  367 

vomit  of,   368 

Yersin's  serum  in  proph\laxis  of  plague, 
T76 


John  Bale,  Sons  &  Daniei.sson,  I-Tn.,  83-91,  Great  Titchfield  Street,  London,  W.i, 


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